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Submission of Significant Hardship Exemption to Avoid the eRx Payment Adjustment
eRx Incentive Program Submission of Significant Hardship Exemption to Avoid the eRx Payment Adjustment
OMB: 0938-1138
IC ID: 197992
OMB.report
HHS/CMS
OMB 0938-1138
ICR 201108-0938-005
IC 197992
( )
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:
Submission of Significant Hardship Exemption to Avoid the eRx Payment Adjustment
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Voluntary
CFR Citation:
42 CFR 414.92
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:
110,106
Number of Respondents for Small Entity:
110,106
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
100 %
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
110,106
0
110,106
0
0
0
Annual IC Time Burden (Hours)
220,212
0
220,212
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.