Information Collection

Submitting Requests for Medical Necessity Disclosures (Potential Participants, Beneficiaries, and Contracting Providers)

IC 220884 under ICR 201604-0938-002 · OMB 0938-1280.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1280 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Submitting Requests for Medical Necessity Disclosures (Potential Participants, Beneficiaries, and Contracting Providers)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 440.395(c)(1) 42 CFR 457.496(e)(1) 42 CFR 438.915(a)

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: 47,467,922	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	142,403	142,403
Annual IC Time Burden (Hours)	35,601	35,601
Annual IC Cost Burden (Dollars)	0	0

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