Information Collection

42 CFR 411.362(b)(5)(i) - Disclosures

IC 182130 under ICR 202105-0938-008 · OMB 0938-1034.

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IC Title:	42 CFR 411.362(b)(5)(i) - Disclosures	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 411.362(b)(5)i

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 81	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-291,416	291,416
Annual IC Time Burden (Hours)	-7,284	7,284
Annual IC Cost Burden (Dollars)	0	0

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