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Premium Payment (2011)
Application for Coverage in the Pre-Existing Condition Insurance Plan
OMB: 0938-1095
IC ID: 193402
OMB.report
HHS/CMS
OMB 0938-1095
ICR 201006-0938-012
IC 193402
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1095 can be found here:
2011-12-19 - Revision of a currently approved collection
2011-11-08 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Premium Payment (2011)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
33,333
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
33,333
33,333
0
0
0
0
Annual IC Time Burden (Hours)
5,333
5,333
0
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
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.