Information Collection

Health Insurance Claim Form, HCFA 1450

IC 5581 under ICR 200811-0720-001 · OMB 0720-0013.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0013 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form UB-92 HCFA-1450 Health Insurance Claim Form, HCFA 1450	Form and Instruction
UB-92 HCFA-1450 Health Insurance Claim Form UB-92 HCFA-1450.doc	Form and Instruction

IC Title:

Health Insurance Claim Form, HCFA 1450

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 32 CFR 199.7

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	UB-92 HCFA-1450	Health Insurance Claim Form	UB-92 HCFA-1450.doc		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,836

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 6 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	21,100,000	21,100,000
Annual IC Time Burden (Hours)	525,000	525,000
Annual IC Cost Burden (Dollars)	893,000	893,000

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.