Information Collection

Individual Notice-Written and E-mail Notice (preparing and documenting notification)

IC 221874 under ICR 202401-0945-002 · OMB 0945-0003.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0945-0003 can be found here:

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Information Collection (IC) Details

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IC Title:	Individual Notice-Written and E-mail Notice (preparing and documenting notification)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR Parts 160 and 164 (To search for a specific CFR, visit the Code of Federal Regulations.)

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: 64,592	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	Previously Approved
Annual Number of Responses for this IC	64,592	6,110	58,482
Annual IC Time Burden (Hours)	32,296	3,055	29,241
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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