Information Collection

Individual Notice-Written and E-mail Notice (preparing and documenting notification)

IC 221874 under ICR 202304-0945-001 · OMB 0945-0003.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0945-0003 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Individual Notice-Written and E-mail Notice (preparing and documenting notification)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 45 CFR Parts 160 and 164 (To search for a specific CFR, visit the Code of Federal Regulations.)

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: 58,482	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	58,482	58,482
Annual IC Time Burden (Hours)	29,241	29,241
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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