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Incentive Arrangement Disclosure Form and Supporting Regulations 42 CFR 417.479, 417.500, 422.208, 422.210, 434.44, 434.67, 434.70, 1003.100, 1003.101, 1003.103, 1003.106
Incentive Arrangement Disclosure Form and Supporting Regulations 42 CFR 417.479, 417.500, 422.208, 422.210, 434.44, 434.67, 434.70, 1003.100, 1003.101, 1003.103, 1003.106
OMB: 0938-0700
IC ID: 8322
OMB.report
HHS/CMS
OMB 0938-0700
ICR 200012-0938-002
IC 8322
( )
Documents and Forms
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Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
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IC Title:
Incentive Arrangement Disclosure Form and Supporting Regulations 42 CFR 417.479, 417.500, 422.208, 422.210, 434.44, 434.67, 434.70, 1003.100, 1003.101, 1003.103, 1003.106
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-R-201
Yes
Yes
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
450
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
70 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
450
0
450
0
0
0
Annual IC Time Burden (Hours)
45,000
0
45,000
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.