Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0997 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-1450 (UB-04) Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5 Form
CMS-1450 (UB-04).Reverse Side-CLEAN DRAFT.doc Instruction
CMS-1450 (UB-04) Medicare Uniform Institutional Provider Bill CMS-1450. UB-04 (2006).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5	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 424.5

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-1450 (UB-04)	Medicare Uniform Institutional Provider Bill	CMS-1450. UB-04 (2006).pdf		Yes	No	Fillable Fileable
Instruction			CMS-1450 (UB-04).Reverse Side-CLEAN DRAFT.doc		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 53,111	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: 99 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	179,489,721	34	179,489,687
Annual IC Time Burden (Hours)	1,786,036	1,786,036	0
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.