Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489 and 491

Health Insurance Benefit Agreement and Supporting Regulations (CMS-1561/1561A)

OMB: 0938-0832

IC ID: 8630

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

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Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489 and 491
 
No Modified
 
Mandatory
 
42 CFR 489 42 CFR 491

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-1561 Health Insurance Benefits Agreement CMS-1561 - Provider Agreement. 05.18.23.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-1561A Health Insurance Benefits Agreement for RHC CMS-1561A..05.18.23.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

2,050 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,050 0 -1,038 0 3,088 0
Annual IC Time Burden (Hours) 2,050 0 -1,038 0 3,088 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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