Information Collection

Requirements in 482.94 (c)(1) & (2)

IC 209063 under ICR 201310-0938-009 · OMB 0938-1069.

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Information Collection (IC) Details

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IC Title:	Requirements in 482.94 (c)(1) & (2)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 482.94(c)(1)(2)

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: 226	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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	226	226
Annual IC Time Burden (Hours)	2,260	2,260
Annual IC Cost Burden (Dollars)	0	0

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