Information Collection

REG-125592-10 (TD 9494), Patient Protection and Affordable Care Act Internal Claims and Appeals and External review Disclosures.

IC 193852 under ICR 202102-1545-021 · OMB 1545-2182.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-2182 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
REG-125592-10 (TD 9494).rtf TD 9494	IC Document
REG-125592-10 (TD 9494).rtf TD 9494	IC Document

IC Title:

REG-125592-10 (TD 9494), Patient Protection and Affordable Care Act Internal Claims and Appeals and External review Disclosures.

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 26 CFR 54.9815-2719T

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

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,769,264

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	278,412	278,412
Annual IC Time Burden (Hours)	2,271	2,271
Annual IC Cost Burden (Dollars)	1,143,236	1,143,236

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
TD 9494	REG-125592-10 (TD 9494).rtf	02/11/2014

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