Information Collection

Health Insurance Claims Form, UB-04 CMS 1450

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1450 UB-04 For Health Insurance Claim Form 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

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-1450 UB-04 Form				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 %

table that charts list of burden
	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

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.

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