Information Collection

Termination of coverage or enrollment for qualified individuals.

IC 242963 under ICR 202401-0938-015 · OMB 0938-1341.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

Termination of coverage or enrollment for qualified individuals.

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 156.270(b)

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: 302

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	302	52	250
Annual IC Time Burden (Hours)	66,440	11,440	55,000
Annual IC Cost Burden (Dollars)	1,100,216	1,100,216	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.