Information Collection

QIO Assumption of Responsibilities and Supp. Regs. in 42 CFR Sections 476.71

IC 185525 under ICR 202501-0938-005 · OMB 0938-0445.

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IC Title:	QIO Assumption of Responsibilities and Supp. Regs. in 42 CFR Sections 476.71	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 476.71

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: 18,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	36,000	24,000	12,000
Annual IC Time Burden (Hours)	90,000	60,000	30,000
Annual IC Cost Burden (Dollars)	0	0	0

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