Information Collection

Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424 Subpart C

IC 8856 under ICR 201211-0938-010 · OMB 0938-0999.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1500(08-05) Health Insurance Claim Form Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424 Subpart C	Form and Instruction
Form CMS-1490-S PATIENT'S REQUEST FOR MEDICAL PAYMENT Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424 Subpart C	Form and Instruction
CMS-1500(08-05) Health Insurance Claim Form CMS1500(08-05).pdf	Form and Instruction
CMS-1490-S PATIENT'S REQUEST FOR MEDICAL PAYMENT CMS1490S English.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: 42 CFR 424 Subpart C

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(08-05)				Yes	Yes	Fillable Fileable
Form and Instruction	CMS-1490-S				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,448,346

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: 86 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	988,005,045	17,830,785	970,174,260
Annual IC Time Burden (Hours)	21,481,336	-11,586,421	33,067,757
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.

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