Prepare and transmit UB-04 or State File for Inpatient and Ambulatory

National Hospital Care Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0212 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0212 Prepare and transmit UB-04 or State File for Inpatient and Ambulatory Form and Instruction
0920-0212 UB-04 or State File for Inpatient and Ambulatory (monthl Att J - Monthly Data Transmission of UB-04 Data.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Prepare and transmit UB-04 or State File for Inpatient and Ambulatory	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0212	UB-04 or State File for Inpatient and Ambulatory (monthly)	Att J - Monthly Data Transmission of UB-04 Data.doc	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0167 Health Resources Utilization Statistics	FR Citation: 49 FR 37693

Number of Respondents: 399	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: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4,788	-984	5,772
Annual IC Time Burden (Hours)	4,788	-984	5,772
Annual IC Cost Burden (Dollars)	0	0	0

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.