Information Collection

Requirements for Requests by Hospitals for an Alternative Cost-to-Charge Ratio and Supp. Regs. in 42CFR412.84(i)(2),412.525(a)(4)(ii), 412.525(a)(4)(iv)(A), 412.529(c)(3)(ii) and 412.529(c)(3)(iv)(A)

IC 178499 under ICR 201006-0938-015 · OMB 0938-1020.

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IC Title:	Requirements for Requests by Hospitals for an Alternative Cost-to-Charge Ratio and Supp. Regs. in 42CFR412.84(i)(2),412.525(a)(4)(ii), 412.525(a)(4)(iv)(A), 412.529(c)(3)(ii) and 412.529(c)(3)(iv)(A)	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 412 84(i)(1) 42 CFR 412 525(a)(4)(ii) 42 CFR 412 525(a)(4)(iv)(A) 42 CFR 412 529(f)(2) 42 CFR 412 529(f)(4)(i)

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: 18	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: 75 %

	Approved	Previously Approved
Annual Number of Responses for this IC	18	18
Annual IC Time Burden (Hours)	144	144
Annual IC Cost Burden (Dollars)	0	0

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