Information Collection

Health Insurance Claim Form, HCFA 1450

IC 5581 under ICR 200506-0720-001 · OMB 0720-0013.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0013 can be found here:

Documents and Forms

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Information Collection (IC) Details

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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

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 Agency Discretion	Previously Approved
Annual Number of Responses for this IC	21,100,000	19,000,000	2,100,000
Annual IC Time Burden (Hours)	525,000	0	525,000
Annual IC Cost Burden (Dollars)	893,000	34,000	859,000

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