Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489 and 491

Health Insurance Benefit Agreement and Supporting Regulations (CMS-1561/1561A)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0832 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-1561 Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489 and 491 Form and Instruction
CMS-1561 Health Insurance Benefits Agreement CMS1561-Provider Agreement.pdf Form and Instruction
CMS-1561A Health Insurance Benefits Agreement for RHC CMS-1561A 508 compliant July 18, 2019.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489 and 491	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 491 42 CFR 489

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1561	Health Insurance Benefits Agreement	CMS1561-Provider Agreement.pdf		No		Paper Only
Form and Instruction	CMS-1561A	Health Insurance Benefits Agreement for RHC	CMS-1561A 508 compliant July 18, 2019.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,088	Number of Respondents for Small Entity: 3,088

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	3,088	634	2,454
Annual IC Time Burden (Hours)	3,088	634	2,454
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.