Information Collection

Requirements in 411.362(b)(5)(i) and 489.20(w)(2) - Attorney

IC 182128 under ICR 201403-0938-005 · OMB 0938-1034.

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Information Collection (IC) Details

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IC Title:	Requirements in 411.362(b)(5)(i) and 489.20(w)(2) - Attorney	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 489.20(w) 42 CFR 411.362(b)(5)(i)

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: 2,557	Number of Respondents for Small Entity: 1,280

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-2,557	2,557
Annual IC Time Burden (Hours)	-10,228	10,228
Annual IC Cost Burden (Dollars)	0	0

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