Information Collection

Pharmacy Billing Requirements

IC 38474 under ICR 201601-1240-010 · OMB 1240-0050.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0050 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Instructions for Required Data Elements for Pharmacy Bills (for 2012).pdf	Instruction

IC Title:

Pharmacy Billing Requirements

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 30.701 20 CFR 725.701 20 CFR 725.705 20 CFR 10.801

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			Instructions for Required Data Elements for Pharmacy Bills (for 2012).pdf		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: DOL/GOVT-1 (FECA); DOL/ESA-6 (BLBA); DOL/ESA-49 (EEOICPA)

FR Citation: 67 FR 16826

Number of Respondents: 4,344

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: 98 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,453,300	-36,232	1,489,532
Annual IC Time Burden (Hours)	24,421	-2,496	26,917
Annual IC Cost Burden (Dollars)	0	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.