Health Insurance Claims Form, UB-04 CMS 1450

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Information Collection (IC) Details

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Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

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Privacy Act System of Records
Title:	FR Citation:

Number of Respondents:	Number of Respondents for Small Entity:

Affected Public:

Percentage of Respondents Reporting Electronically:

		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
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Annual IC Time Burden (Hours)
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.