Information Collection

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

IC 8856 under ICR 200706-0938-011 · OMB 0938-0999.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0999 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-1500 (08-05) Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424 Subpart C Form and Instruction
CMS-1500 (08-05) Health Insurance Claim Form CMS1500805.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 424 Subpart C

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1500 (08-05)	Health Insurance Claim Form	CMS1500805.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,048,243	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 86 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	970,174,260	12,969,553	957,204,707
Annual IC Time Burden (Hours)	33,067,757	-13,315,607	46,383,364
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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