Information Collection

Retrospective Appeal Requests

IC 264664 under ICR 202410-0938-017 · OMB 0938-1466.

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Retrospective Appeal Requests	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 405.932

Information Collection 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: 32,894	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,579	6,579
Annual IC Time Burden (Hours)	3,290	3,290
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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