Information Collection

Separately Billing Doctors Form

IC 191104 under ICR 202406-0935-002 · OMB 0935-0118.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0118 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 59 Separately Billing Doctors Form	Form and Instruction
59 Separately Billing Doctors Event Form Attachment 59 -- Separately Billing Doctors Event Form.docx	Form and Instruction
59 Separately Billing Doctors Event Form Attachment 59 -- Separately Billing Doctors Event Form.docx	Form and Instruction

IC Title:

Separately Billing Doctors Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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
Form and Instruction	59	Separately Billing Doctors Event Form	Attachment 59 -- Separately Billing Doctors Event Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,676

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 Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,611	-12,155	17,766
Annual IC Time Burden (Hours)	281	-607	888
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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