Information Collection

Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5

IC 243027 under ICR 202401-0720-001CF · OMB 0938-0997.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1450 (UB04) Fr Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5	Form and Instruction
CMS-1450 (UB04) Fr Uniform Institutional Providers Form CMS-1450 UB04-front.pdf	Form and Instruction
CMS-1450 (UB04) Ba Uniform Institutional Providers Form CMS-1450 UB04 - Back.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 424.5

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1450 (UB04) Front	Uniform Institutional Providers Form	CMS-1450 UB04-front.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-1450 (UB04) Back	Uniform Institutional Providers Form	CMS-1450 UB04 - Back.pdf		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,318

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	858,881	0	858,881
Annual IC Time Burden (Hours)	8,589	1,395	7,194
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.