Information Collection

483.10(f)(4)(v) through 483.10(f)(4)(vi)

IC 236450 under ICR 201901-0938-005 · OMB 0938-1363.

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Documents and Forms

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IC Title:

483.10(f)(4)(v) through 483.10(f)(4)(vi)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 483.10(f)(4)(v) through 483.10

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,639

Number of Respondents for Small Entity: 15,639

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	15,639	15,639
Annual IC Time Burden (Hours)	39,098	39,098
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.