Information Collection

Submitting a Prior Authorization Request and Mailing Medical Records

IC 212039 under ICR 201509-0938-004 · OMB 0938-1293.

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Information Collection (IC) Details

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IC Title:	Submitting a Prior Authorization Request and Mailing Medical Records	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.234(c)

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: 157,500	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 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	157,500	157,500
Annual IC Time Burden (Hours)	78,750	78,750
Annual IC Cost Burden (Dollars)	1,578,150	1,578,150

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