Information Collection

Prepare and transmit UB-04 for Inpatient and Ambulatory

IC 186285 under ICR 201302-0920-001 · OMB 0920-0212.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0212 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Prepare and transmit UB-04 for Inpatient and Ambulatory	Form
Quarterly Transmission of UB-04 Data NHCS 2013 Attac N- Quarterly Data Transmission 011613.doc	Form
Attachment Q- List of UB04 Data Elements.docx Att Q - UB-04 Data Elements	IC Document

IC Title:

Prepare and transmit UB-04 for Inpatient and Ambulatory

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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	none	Quarterly Transmission of UB-04 Data	NHCS 2013 Attac N- Quarterly Data Transmission 011613.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0167 Health Resources Utilization Statistics

FR Citation: 49 FR 37697

Number of Respondents: 500

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,000	1,989	11
Annual IC Time Burden (Hours)	2,000	1,989	11
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att Q - UB-04 Data Elements	Attachment Q- List of UB04 Data Elements.docx	01/31/2013

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