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The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376
The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376
OMB: 0938-0270
IC ID: 7923
OMB.report
HHS/CMS
OMB 0938-0270
ICR 200107-0938-013
IC 7923
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0270 can be found here:
2024-11-05 - Reinstatement without change of a previously approved collection
2020-03-24 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376
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:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
HCFA-379
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
500
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
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
500
0
0
0
0
500
Annual IC Time Burden (Hours)
1,000
0
0
0
0
1,000
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.