Information Collection

Section 2719A - Patient Protections

IC 193322 under ICR 201904-0938-015 · OMB 0938-1094.

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IC Title:

Section 2719A - Patient Protections

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 147.138

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: 920

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 38 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	53,360	-461,948	515,308
Annual IC Time Burden (Hours)	230	-455	685
Annual IC Cost Burden (Dollars)	1,334	-11,549	12,883

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