Information Collection

Form 13560, HCTC Health Plan Administrator (HPA) Return of Funds Form, and Form 13561, HCTC Health Plan Administrators Operations Guide

IC 19574 under ICR 200410-1545-017 · OMB 1545-1891.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-1891 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

Form 13560, HCTC Health Plan Administrator (HPA) Return of Funds Form, and Form 13561, HCTC Health Plan Administrators Operations Guide

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
Form	13560				No	No
Form	13561				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

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.