Information Collection

Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489 and 491

IC 8630 under ICR 201401-0938-016 · OMB 0938-0832.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0832 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1561 Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489 and 491	Form and Instruction
CMS-1561 Health Insurance Benefits Agreement cms1561.pdf	Form and Instruction
CMS-1561A Health Insurance Benefits Agreement for RHC CMS1561A.pdf	Form and Instruction

IC Title:

Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489 and 491

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 489 42 CFR 491

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 and Instruction	CMS-1561	Health Insurance Benefits Agreement	cms1561.pdf		No	No	Paper Only
Form and Instruction	CMS-1561A	Health Insurance Benefits Agreement for RHC	CMS1561A.pdf		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,000

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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