Information Collection

Medicaid - Determining Third Party Liability (TPL) State Plan Preprint and Supporting Regulation in 42 CFR 433.138

IC 8123 under ICR 200903-0938-010 · OMB 0938-0502.

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IC Title:	Medicaid - Determining Third Party Liability (TPL) State Plan Preprint and Supporting Regulation in 42 CFR 433.138	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 433.138

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,900,000	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,900,000	200,000	2,700,000
Annual IC Time Burden (Hours)	510,968	38,709	472,259
Annual IC Cost Burden (Dollars)	0	0	0

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