Information Collection

483.80(d)(3)(vi) & (vii)

IC 254162 under ICR 202206-0938-011 · OMB 0938-1363.

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Information Collection (IC) Details

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IC Title:	483.80(d)(3)(vi) & (vii)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 483.80(d)(3)(vi) & (vii)

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: 15,600	Number of Respondents for Small Entity: 15,600

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	187,200	187,200
Annual IC Time Burden (Hours)	93,600	93,600
Annual IC Cost Burden (Dollars)	0	0

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