OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

SBC Disclosure

IC 199007 under ICR 201909-0938-002 · OMB 0938-1146.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Maternity-Care-Narrative.pdf Other-Maternity Care Narrative
Diabetes-Narrative.pdf Other-Diabetes 2 Narrative
List of Anchors_Updated.xlsx Other-Uniform Glossary Anchor
Why_this_Matters_for_SBC_No_Answers_English.pdf Other-What the Plan Covers and What
Why_this_Matters_for_SBC_Yes_Answers_English.pdf Other-Why This Matters for SBC (Yes
Group_Instructions_Updated.pdf Instruction
Individual_Instructions_Updated.pdf Instruction
Sample_Completed_SBC_Standard_Format.docx Other-Completed SBC Template
SBC_Template_Standard_Format_Updated.docx Other-SBC Template
Foot-Fracture-Narrative.pdf Other-Foot Fracture Narrative
Coverage-Examples-Calculator-Instructions.pdf Instruction
SBC-Coverage-Examples-Calculator-Excel.xlsm Other-Coverage Calculator
Having-a-Baby-Guide.xlsx Other-Template
Managing-Type-2-Diabetes-Guide.pdf Other-Diabetes Guide
List of Anchors_Updated.xlsx Other-Glossary Anchor
Simple-Fracture-Guide_508.pdf Other-Template
AIAN Limited Cost Sharing.pdf Instruction
AIAN_Zero_Cost_Sharing.pdf Instruction
Uniform Glossary_Updated.pdf Other-Uniform Glossary

Information Collection (IC) Details

View Information Collection (IC)

layout table

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
Other-Coverage Calculator SBC-Coverage-Examples-Calculator-Excel.xlsm Yes No Fillable Printable
Other-Diabetes Guide Managing-Type-2-Diabetes-Guide.pdf Yes No Printable Only
Other-Glossary Anchor List of Anchors_Updated.xlsx Yes No Printable Only
Instruction AIAN Limited Cost Sharing.pdf Yes No Printable Only
Instruction AIAN_Zero_Cost_Sharing.pdf Yes No Printable Only
Other-Diabetes 2 Narrative Diabetes-Narrative.pdf Yes No Printable Only
Other-Template Having-a-Baby-Guide.xlsx Yes No Printable Only
Instruction Individual_Instructions_Updated.pdf Yes No Printable Only
Other-Maternity Care Narrative Maternity-Care-Narrative.pdf Yes No Printable Only
Other-Uniform Glossary Uniform Glossary_Updated.pdf Yes No Printable Only
Other-Uniform Glossary Anchor List of Anchors_Updated.xlsx Yes No Printable Only
Other-What the Plan Covers and What You Pay (No Answers) Why_this_Matters_for_SBC_No_Answers_English.pdf Yes No Printable Only
Other-Why This Matters for SBC (Yes Answers) Why_this_Matters_for_SBC_Yes_Answers_English.pdf Yes No Printable Only
Instruction Group_Instructions_Updated.pdf Yes No Printable Only
Other-Completed SBC Template Sample_Completed_SBC_Standard_Format.docx Yes No Fillable Fileable
Other-SBC Template SBC_Template_Standard_Format_Updated.docx Yes No Fillable Fileable
Other-Foot Fracture Narrative Foot-Fracture-Narrative.pdf Yes No Printable Only
Instruction Coverage-Examples-Calculator-Instructions.pdf Yes No Printable Only
Other-Template Simple-Fracture-Guide_508.pdf Yes No Printable Only

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 41,804,628 0 0 639,865 0 41,164,763
Annual IC Time Burden (Hours) 214,791 0 0 -110,062 0 324,853
Annual IC Cost Burden (Dollars) 4,180,463 0 0 63,987 0 4,116,476

Documents for IC
table that charts IC Documents
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.