Information Collection

Application for Enrollment in Part B Immunosuppressive Drug Coverage (Part B-ID)

IC 254490 under ICR 202210-0938-008 · OMB 0938-1428.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	Application for Enrollment in Part B Immunosuppressive Drug Coverage (Part B-ID)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 407.1(a)(6)

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: 767	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	767	767
Annual IC Time Burden (Hours)	128	128
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.