Information Collection

Provider Report

IC 269446 under ICR 202407-0906-003 · OMB 0906-0039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0039 can be found here:

Documents and Forms

Document Name Document Type
Form 2 Provider Report Form and Instruction
2 Provider Report 2024 RSR Provider forms (OMB Submission)_Redacted.pdf Form and Instruction
2 Provider Report 2024 RSR Provider forms (OMB Submission)_Redacted.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Provider Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	Provider Report	2024 RSR Provider forms (OMB Submission)_Redacted.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,063	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,063	2,063
Annual IC Time Burden (Hours)	26,819	26,819
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.