Information Collection

Health Insurance Claims Form, UB-04 CMS 1450

IC 5581 under ICR 201705-0720-002 · OMB 0720-0013.

Documents and Forms

Document Name Document Type
Form CMS-1450 UB-04 For Health Insurance Claims Form, UB-04 CMS 1450 Form
CMS-1450 UB-04 For Health Insurance Claim Form CMS-1450 UB-04 Form.PDF Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Insurance Claims Form, UB-04 CMS 1450	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-1450 UB-04 Form	Health Insurance Claim Form	CMS-1450 UB-04 Form.PDF		Yes	Yes	Fillable Printable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,318	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 86 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	858,881	-20,241,119	21,100,000
Annual IC Time Burden (Hours)	41,884	-483,116	525,000
Annual IC Cost Burden (Dollars)	715,632	-177,368	893,000

Documents for IC

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.