Medicare Integrity Program Organizations Conflict of Interest Disclosure Certificate and Supporting Regulations at 42 CFR 421.300 - 421.318

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IC Title:	Medicare Integrity Program Organizations Conflict of Interest Disclosure Certificate and Supporting Regulations at 42 CFR 421.300 - 421.318	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

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-232				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	2,400	2,400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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