Information Collection

Submission of Significant Hardship Exemption to Avoid the eRx Payment Adjustment

IC 197992 under ICR 201108-0938-005 · OMB 0938-1138.

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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:

table that charts list of 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: 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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	110,106	110,106
Annual IC Time Burden (Hours)	220,212	220,212
Annual IC Cost Burden (Dollars)	0	0

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