Information Collection

Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5

IC 43681 under ICR 201602-0938-007 · OMB 0938-0997.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0997 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1450 (UB04) Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5	Form and Instruction
CMS-1450 (UB04) Uniform Institutional Providers Form UB-04 Front Back w_OMB_08_19.pdf	Form and Instruction

IC Title:

Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5

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 424.5

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
Form and Instruction	CMS-1450 (UB04)	Uniform Institutional Providers Form	UB-04 Front Back w_OMB_08_19.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 53,111

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: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	204,138,881	22,229,227	181,909,654
Annual IC Time Burden (Hours)	1,730,077	162,622	1,567,455
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.