Information Collection

Medical Services Coverage Decisions That Relate to Health Care Technology (42 CFR 405.211)

IC 209667 under ICR 201901-0938-010 · OMB 0938-1250.

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Information Collection (IC) Details

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IC Title:	Medical Services Coverage Decisions That Relate to Health Care Technology (42 CFR 405.211)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 405.211

Information Collection 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: 100	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	100	-140	240
Annual IC Time Burden (Hours)	200	-280	480
Annual IC Cost Burden (Dollars)	0	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.