Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0997 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-1450 (UB04) Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5 Form
CMS-1450 UB04 - Back.pdf Instruction
CMS-1450 (UB04) Uniform Institutional Providers Form CMS-1450 UB04-front.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5	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 424.5

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-1450 (UB04)	Uniform Institutional Providers Form	CMS-1450 UB04-front.pdf		Yes	Yes	Fillable Fileable
Instruction			CMS-1450 UB04 - Back.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 53,111	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: 99 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	181,909,654	181,909,654
Annual IC Time Burden (Hours)	1,567,455	1,567,455
Annual IC Cost Burden (Dollars)	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.