Information Collection

Certificates for Health Care Benefits

IC 20365 under ICR 200303-1615-064 · OMB 1615-0062.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

Certificates for Health Care Benefits

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

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	21,000	21,000
Annual IC Time Burden (Hours)	37,240	37,240
Annual IC Cost Burden (Dollars)	4,550,000	4,550,000

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.