Information Collection

Limitation on Liability and Information Collection Requirements Referenced in 42 CFR 411.404, 411.406, and 411.408

IC 8086 under ICR 200009-0938-008 · OMB 0938-0465.

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IC Title:

Limitation on Liability and Information Collection Requirements Referenced in 42 CFR 411.404, 411.406, and 411.408

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-R-77				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 890,826

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,563,304	665,200	2,898,104
Annual IC Time Burden (Hours)	296,942	55,433	241,509
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.