Information Collection

Average Sales Price: Price Concessions and Bona Fide Service Fees (§§ 414.802 and 414.804)

IC 277540 under ICR 202508-0938-003 · OMB 0938-0921.

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Information Collection (IC) Details

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IC Title:	Average Sales Price: Price Concessions and Bona Fide Service Fees (§§ 414.802 and 414.804)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.802 and 414.804

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: 435	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 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	870	870
Annual IC Time Burden (Hours)	10,875	10,875
Annual IC Cost Burden (Dollars)	0	0

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