Information Collection

42 CFR 489.20(w)(1) - (5) - Disclosures

IC 182129 under ICR 201403-0938-005 · OMB 0938-1034.

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Information Collection (IC) Details

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IC Title:	42 CFR 489.20(w)(1) - (5) - Disclosures	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 489.20(w)

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: 2,597	Number of Respondents for Small Entity: 1,307

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,105,702	2,313,458	2,792,244
Annual IC Time Burden (Hours)	127,752	57,946	69,806
Annual IC Cost Burden (Dollars)	0	0	0

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