Information Collection

Third Party Premium Billing Request and Supporting Regulations in 42 CFR 408.6 and 408.202

IC 7794 under ICR 200310-0938-001 · OMB 0938-0041.

Documents and Forms

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IC Title:

Third Party Premium Billing Request and Supporting Regulations in 42 CFR 408.6 and 408.202

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Voluntary

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
Form	CMS-2384				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 17,350

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	17,350	2,350	15,000
Annual IC Time Burden (Hours)	6,446	196	6,250
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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Title	Document	Date Uploaded

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

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