Information Collection

Appendix A - Agents and Brokers - Data Elements for General Function of an Exchange (Part 155, Subpart C)

IC 226005 under ICR 201703-0938-008 · OMB 0938-1329.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1329 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix A - Agents and Brokers_.docx	Instruction

IC Title:

Appendix A - Agents and Brokers - Data Elements for General Function of an Exchange (Part 155, Subpart C)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.220

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			Appendix A - Agents and Brokers_.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 160

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 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	160	160
Annual IC Time Burden (Hours)	320	320
Annual IC Cost Burden (Dollars)	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.