Information Collection

Section 493.1359- 493.1489-1491

IC 264337 under ICR 202401-0938-001 · OMB 0938-0612.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0612 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
2024.01.29_CMS3326F Crosswalk with Dtags and IGs_DRAFT_pk.xlsx Crosswalk	IC Document
2024.01.29_CMS3326F-Crosswalk w D-tags_DRAFT_PK.docx Crosswalk	IC Document

IC Title:

Section 493.1359- 493.1489-1491

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 493.1359- 493.1489-1491

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 34,082

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	34,082	34,082
Annual IC Time Burden (Hours)	238,574	238,574
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	2024.01.29_CMS3326F Crosswalk with Dtags and IGs_DRAFT_pk.xlsx	06/03/2024
Crosswalk	2024.01.29_CMS3326F-Crosswalk w D-tags_DRAFT_PK.docx	06/03/2024

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