Information Collection

PHS Assignment Request Form

IC 217564 under ICR 202004-0925-002 · OMB 0925-0001.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0001 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 14 PHS Assignment Request Form	Form
14 PHS Assignment Request Form Attachment 5C PHS Assignment Request Form_FORMS-F.pdf	Form
Attachment 5B_PHS Assignment Request Form_Instructions_FORMS-F.pdf PHS Assignment Request Instructions	IC Document

IC Title:

PHS Assignment Request 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	14	PHS Assignment Request Form	Attachment 5C PHS Assignment Request Form_FORMS-F.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,354

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3,354	3,354
Annual IC Time Burden (Hours)	1,677	1,677
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PHS Assignment Request Instructions	Attachment 5B_PHS Assignment Request Form_Instructions_FORMS-F.pdf	12/27/2019

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