Information Collection

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

IC 8856 under ICR 200606-0938-013 · OMB 0938-0999.

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Information Collection (IC) Details

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IC Title:	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-1490S				Yes	Yes
Form	CMS-1500(08-05)				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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	957,204,707	957,204,707
Annual IC Time Burden (Hours)	46,383,364	46,383,364
Annual IC Cost Burden (Dollars)	0	0

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Title	Document	Date Uploaded

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