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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.