Information Collection

SBC Disclosure

IC 199007 under ICR 201911-0938-018 · OMB 0938-1146.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1146 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document 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

IC Title:

SBC Disclosure

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 147.200

Information Collection Instruments:

table that charts list of instruments
Document Type	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Maternity Care Narrative	Yes	No	Printable Only
Other-Diabetes 2 Narrative	Yes	No	Printable Only
Other-Uniform Glossary Anchor	Yes	No	Printable Only
Other-What the Plan Covers and What You Pay (No Answers)	Yes	No	Printable Only
Other-Why This Matters for SBC (Yes Answers)	Yes	No	Printable Only
Instruction	Yes	No	Printable Only
Instruction	Yes	No	Printable Only
Other-Completed SBC Template	Yes	No	Fillable Fileable
Other-SBC Template	Yes	No	Fillable Fileable
Other-Foot Fracture Narrative	Yes	No	Printable Only
Instruction	Yes	No	Printable Only
Other-Coverage Calculator	Yes	No	Fillable Printable
Other-Template	Yes	No	Printable Only
Other-Diabetes Guide	Yes	No	Printable Only
Other-Glossary Anchor	Yes	No	Printable Only
Other-Template	Yes	No	Printable Only
Instruction	Yes	No	Printable Only
Instruction	Yes	No	Printable Only
Other-Uniform Glossary	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 128,511

Number of Respondents for Small Entity: 35

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 70 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	41,804,628	41,804,628
Annual IC Time Burden (Hours)	214,791	214,791
Annual IC Cost Burden (Dollars)	4,180,463	4,180,463

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.

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