Information Collection

Uninsured Provider (UIP) Application

IC 251212 under ICR 202201-0906-002 · OMB 0906-0069.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Uninsured Provider (UIP) Application	Form
4 UIP_Portal_Screenshots.docx UIP_Portal_Screenshots.docx	Form
4 UIP_Portal_Screenshots.docx UIP_Portal_Screenshots.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	4	UIP_Portal_Screenshots.docx	UIP_Portal_Screenshots.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 280,000

Number of Respondents for Small Entity: 10,000

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	280,000	280,000
Annual IC Time Burden (Hours)	280,000	280,000
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.