Information Collection

Medicare Secondary Payer Information Collection

IC 7889 under ICR 200906-0938-006 · OMB 0938-0214.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0214 can be found here:

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Information Collection (IC) Details

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IC Title:	Medicare Secondary Payer Information Collection	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 489.20 42 CFR 411.25 42 CFR 489.2

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: 143,070,217	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	143,070,217	18,516,535	124,553,682
Annual IC Time Burden (Hours)	1,788,057	176,754	1,611,303
Annual IC Cost Burden (Dollars)	0	0	0

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