Uninsured Provider (UIP) Application

COVID–19 Provider Relief Programs Application and Attestation Portal, and Claims Reimbursement Submission Activities

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Uninsured Provider (UIP) Application	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:

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 %

	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

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.