Information Collection

Probe Review (Provider Specific)

IC 8829 under ICR 201506-0938-005 · OMB 0938-0969.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0969 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
PIM ADR color coded.doc	Instruction

IC Title:

Probe Review (Provider Specific)

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 421.304 42 CFR 421.200 42 CFR 421.210

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
Instruction			PIM ADR color coded.doc		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 23,400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	23,400	23,400
Annual IC Time Burden (Hours)	11,700	11,700
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.