Information Collection

Health Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424, Subpart C

IC 7761 under ICR 200603-0938-005 · OMB 0938-0008.

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IC Title:

Health Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424, Subpart C

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.	Available Electronically?	Can Be Submitted Electronically?
Form	CMS-1490S	Yes	Yes
Form	CMS-1500(12-90)	Yes	Yes
Form	CMS-1490U	Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 902,378

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 86 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	957,204,707	216,989,572	740,215,135
Annual IC Time Burden (Hours)	46,383,364	2,194,357	44,189,007
Annual IC Cost Burden (Dollars)	0	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.