Information Collection

Claims Denial Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Paper]

IC 191601 under ICR 201908-0938-016 · OMB 0938-1080.

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Information Collection (IC) Details

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IC Title:	Claims Denial Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Paper]	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 146.136(d)(2)

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: 78,126	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	109,973	109,973
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	318,647	318,647

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