Information Collection

Private Practice Option Form

IC 209461 under ICR 202004-0915-004 · OMB 0915-0127.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0127 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Private Practice Option Form	Form and Instruction
5 PPO Agreement_Final_Clean.pdf 2020.pdf PPO Agreement_Final_Clean.pdf 2020.pdf	Form and Instruction

IC Title:

Private Practice Option Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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
Form and Instruction	5	PPO Agreement_Final_Clean.pdf 2020.pdf	PPO Agreement_Final_Clean.pdf 2020.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 330

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	330	330
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	0	0

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.