Information Collection

Submitting Payment Information

IC 234085 under ICR 202411-1652-007 · OMB 1652-0039.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 600 Authorization for Disclosure of Protected Health Information Pursuant to HIPAA Submitting Payment Information	Form and Instruction
0-0-1 Approval.rtf	Other-Letter
0-0-1 Approval.rtf	Other-Letter
0-0-2 Settlement.rtf	Other-Letter
0-0-2 Settlement.rtf	Other-Letter
0-0-9 Reeval- Settlement.rtf	Other-Letter
0-0-9 Reeval- Settlement.rtf	Other-Letter
0-0-10 Reeval -Settlement 50%.rtf	Other-Letter
0-0-10 Reeval -Settlement 50%.rtf	Other-Letter
TSA-Form600_FINALv240603 (1_PRAstmt).docx	Other-PRA Stmt Mockup
TSA-Form600_FINALv240603 (1_PRAstmt).docx	Other-PRA Stmt Mockup
600 Authorization for Disclosure of Protected Health Informa TSA-Form600_FINALv240603 (1).pdf	Form and Instruction
600 Authorization for Disclosure of Protected Health Informa TSA-Form600_FINALv240603 (1).pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Letter		Yes	Yes	Fillable Printable
Other-Letter		Yes	Yes	Fillable Printable
Other-Letter		Yes	Yes	Fillable Printable
Other-Letter		Yes	Yes	Fillable Printable
Form and Instruction	600	Yes	Yes	Fillable Fileable
Other-PRA Stmt Mockup		Yes	Yes	Fillable Fileable

Line of Business: Homeland Security

Subfunction: Border and Transportation Security

Privacy Act System of Records

Title: DHS/TSA 013 DHS Claims Records

FR Citation: 73 FR 63987

Number of Respondents: 900

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	900	-350	1,250
Annual IC Time Burden (Hours)	150	-58	208
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.

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