Information Collection

DE Entities to Implement the Standardized Disclaimer Requirement

IC 263330 under ICR 202404-0938-015 · OMB 0938-1463.

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IC Title:

DE Entities to Implement the Standardized Disclaimer Requirement

Agency IC Tracking Number:

CCIIO -10877

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.221(b)(2)):

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: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	31,324	31,324

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