Information Collection

Health Insurance Claim Form

IC 5564 under ICR 201207-0720-001 · OMB 0720-0001.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS 1500 Health Insurance Claim Form	Form and Instruction
CMS 1500 Health Insurance Claim From CMS1500805.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 32 CFR 199.7

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
Form and Instruction	CMS 1500	Health Insurance Claim From	CMS1500805.pdf		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 86,000,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 84 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	86,000,000	62,000,000	24,000,000
Annual IC Time Burden (Hours)	14,333,333	8,333,333	6,000,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.