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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Information Collection (IC) Details

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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:

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 %

	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.