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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.