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Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489 and 491

IC 8630 under ICR 202511-0938-018 · OMB 0938-0832.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

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Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489 and 491
 
No Modified
 
Mandatory
 
42 CFR 489 42 CFR 491

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-1561 Health Insurance Benefits Agreement CMS-1561 - Provider Agreement (Clean Correction).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-1561A Health Insurance Benefits Agreement for RHC CMS-1561A (Clean Correction).pdf Yes Yes Fillable Fileable

Health Health Care Services

 

2,050 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,050 0 0 0 0 2,050
Annual IC Time Burden (Hours) 2,050 0 0 0 0 2,050
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CMS-1561 (tracked version) CMS-1561 - Provider Agreement (Tracked Correction).docx 11/25/2025
CMS-1561A (Tracked version) CMS-1561A (Tracked Correction).docx 11/25/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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