Medical Expense Report

Medical Expense Report

OMB: 2900-0161

IC ID: 28397

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Medical Expense Report
 
No Migrated
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 21-8416 No No


    

96,400 0
   
Individuals or Households
 
   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 96,400 0 0 0 0 96,400
Annual IC Time Burden (Hours) 48,200 0 0 0 0 48,200
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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