Information Collection

Establishing Creditable Coverage under Group Health Plans

IC 38420 under ICR 201211-1210-004 · OMB 1210-0103.

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IC Title:	Establishing Creditable Coverage under Group Health Plans	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2520.104b-1 29 CFR 2590.701-5

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: 2,283,712	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: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	8,164,356	-11,429,400	19,593,756
Annual IC Time Burden (Hours)	74,000	-14,066	88,066
Annual IC Cost Burden (Dollars)	12,400,000	-1,430,615	13,830,615

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