Exhibit 4 (Initial and Reconciliation)

Please complete this document one time for EACH form/instrument (one time per line item in your burden table). Highlight your response.

1. Title for this form/instrument: Exhibit 4 (Initial and Reconciliation)

2. What is the obligation to respond to this document (select one only):

1. Voluntary – when the response is entirely discretionary and has no direct effect on any benefit or privilege.

2. Required to obtain or retain benefits – when the response is elective but is required to obtain or retain a benefit.

3. Mandatory – when the respondent must reply or face civil or criminal sanctions.

3. Frequency of reporting on this document (this should reflect the number in the burden table under the “Responses per Respondent” column):

1. Hourly

2. Daily

3. Weekly

4. Monthly

5. Yearly

6. Every Decade

7. Quarterly

8. Semi-annually

9. Biennially (every other year)

10. Once

11. Occasionally

4. What are the electronic capabilities to this document (select one only):

1. Paper only

2. Printable only

3. Fillable & printable

4. Fillable & can submit electronically (fileable)

5. What is the document type (select one only):

1. Form & instruction

2. Form

3. Instruction

4. Other

6. Number of small entity respondents for this form/instrument:

A small entity may be (1) a small business which is deemed to be one that is independently owned and operated and that is not dominant it its field of operation; (2) a small organization that is any not-for-profit enterprise that is independently owned and operated and is not dominant in its field; (3) a small government jurisdiction which is a government of a city, county, town, township, school district, or special district with a population of less than 50,000. None

7. Estimated percent of respondents who can submit electronically: 30 auditors and 60 hospitals

8. Affected Public (who are the respondents to this form/instrument) Select ONE only:

1. Individuals or households

2. State, Local, or Tribal Governments

3. Federal Government

4. Private Sector (If Private Sector, please specify: business or other for-profits, not-for-profit institutions, farms)
   
   Business and for-profit and not-for-profit hospitals