Information Collection

Medicaid - Determining Third Party Liability (TPL) State Plan Preprint and Supporting Regulation in 42 CFR 433.138

IC 8123 under ICR 200601-0938-006 · OMB 0938-0502.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0502 can be found here:

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Information Collection (IC) Details

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IC Title:	Medicaid - Determining Third Party Liability (TPL) State Plan Preprint and Supporting Regulation in 42 CFR 433.138	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	CMS-R-0107				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,700,000	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,700,000	800,000	1,900,000
Annual IC Time Burden (Hours)	472,259	142,294	329,965
Annual IC Cost Burden (Dollars)	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.