Information Collection

Face-to-Face encounter, form development (424.22 first year)-One Time Form Revision

IC 195703 under ICR 201612-0938-005 · OMB 0938-1083.

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Information Collection (IC) Details

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IC Title:	Face-to-Face encounter, form development (424.22 first year)-One Time Form Revision	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 424.22(a)(1)(v)

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: 11,327	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	Previously Approved
Annual Number of Responses for this IC	11,327	1,895	9,432
Annual IC Time Burden (Hours)	5,664	948	4,716
Annual IC Cost Burden (Dollars)	0	0	0

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