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

Documents and Forms

Document Name Document Type
Form CMS-1500(08-05) 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

Information Collection (IC) Details

View Information Collection (IC)

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

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1500(08-05)	Health Insurance Claim Form	CMS1500(08-05).pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-1490-S	PATIENT'S REQUEST FOR MEDICAL PAYMENT	CMS1490S English.pdf		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 %

	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

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