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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

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.