Information Collection

Service Level Data Collection for Initial Determinations and Appeals

IC 275516 under ICR 202505-0938-016 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Service Level Data Collection_.docx	Instruction
Service Level Data Collection_508.docx	Instruction
Service Level Data Collection_508redline.pdf Track Change - Service Level Data Collection	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.516 (a) 42 CFR 422.514 (a) 42 CFR 423.505(f)(2) 42 CFR 422.505(f)(3) 42 CFR 422.504(f)(2)

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
Instruction					Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 728

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	2,912	2,912
Annual IC Time Burden (Hours)	1,456	1,456
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change - Service Level Data Collection		09/09/2025

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

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