Information Collection

Qualification Application and Supporting Regulations in 42 CFR, Section 417.408 and 417.143

IC 8096 under ICR 200009-0938-002 · OMB 0938-0470.

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Information Collection (IC) Details

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IC Title:	Qualification Application and Supporting Regulations in 42 CFR, Section 417.408 and 417.143	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-901-1				Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 35	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	35	-30	65
Annual IC Time Burden (Hours)	3,500	-3,000	6,500
Annual IC Cost Burden (Dollars)	471,000	471,000	0

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