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Emergency and Foreign Hospital Services - Beneficiary Statement in Canadian Travel Claims and Supporting Regulations in 42 CFR, Section 424.123
Emergency and Foreign Hospital Services - Beneficiary Statement in Canadian Travel Claims and Supporting Regulations in 42 CFR, Section 424.123
OMB: 0938-0484
IC ID: 8108
OMB.report
HHS/CMS
OMB 0938-0484
ICR 200302-0938-005
IC 8108
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0484 can be found here:
2006-09-15 - 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:
Emergency and Foreign Hospital Services - Beneficiary Statement in Canadian Travel Claims and Supporting Regulations in 42 CFR, Section 424.123
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
CMS-R-96
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
1,100
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
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
1,100
0
0
0
0
1,100
Annual IC Time Burden (Hours)
275
0
0
0
0
275
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.