Information Collection

Information Collection Requirements Referenced in HIPAA for the Group Market, Supporting Regulations 45 CFR 146, and forms/instructions (CMS-R-206)

IC 43664 under ICR 200907-0938-002 · OMB 0938-0702.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0702 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
R-206 HIPAA letter Version 2.doc	Other-Letter
R-206 NMHPA letter.doc	Other-Letter
R-206 WHCRA letter.doc	Other-Letter
R-206 Opt Out Model Language.doc R-206 Opt Out Model Language	IC Document
R-206 Respondents Burden Hours Version2.xls R-206 Respondents Burden Hours Version2	IC Document

IC Title:

Information Collection Requirements Referenced in HIPAA for the Group Market, Supporting Regulations 45 CFR 146, and forms/instructions (CMS-R-206)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 146.111 45 CFR 146.115 45 CFR 146.117 45 CFR 146.150 45 CFR 146.152 45 CFR 146.160 45 CFR 146.180

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Letter	R-206 HIPAA letter Version 2.doc	Yes	Yes	Paper Only
Other-Letter	R-206 NMHPA letter.doc	Yes	Yes	Paper Only
Other-Letter	R-206 WHCRA letter.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,400

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: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	36,902,550	-99,667	37,002,217
Annual IC Time Burden (Hours)	2,918,783	2,472,104	446,679
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
R-206 Opt Out Model Language	R-206 Opt Out Model Language.doc	06/26/2009
R-206 Respondents Burden Hours Version2	R-206 Respondents Burden Hours Version2.xls	06/26/2009

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