Information Collection

483.80(d)(3)(ii) & (iii)

IC 254159 under ICR 202407-0938-017 · OMB 0938-1363.

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IC Title:

483.80(d)(3)(ii) & (iii)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 483.80(d)(3)(ii) & (iii)

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: 15,600

Number of Respondents for Small Entity: 15,600

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	Previously Approved
Annual Number of Responses for this IC	15,600	15,600
Annual IC Time Burden (Hours)	62,400	62,400
Annual IC Cost Burden (Dollars)	0	0

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