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Health Insurance Claim Form, HCFA 1450
Health Insurance Claim Form, HCFA 1450
OMB: 0720-0013
IC ID: 5581
OMB.report
DOD/DODOASHA
OMB 0720-0013
ICR 200506-0720-001
IC 5581
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0013 can be found here:
2017-05-12 - Reinstatement with change of a previously approved collection
2012-01-31 - 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:
Health Insurance Claim Form, HCFA 1450
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
UB-92
Yes
Yes
Form
HCFA-1450
Yes
Yes
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
7,836
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
6 %
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
21,100,000
0
19,000,000
0
0
2,100,000
Annual IC Time Burden (Hours)
525,000
0
0
0
0
525,000
Annual IC Cost Burden (Dollars)
893,000
0
34,000
0
0
859,000
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.