Information Collection

Hospital Eligibility and Registration Form

IC 278418 under ICR 202512-0935-004 · OMB 0935-0162.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Hospital Eligibility and Registration Form	Form and Instruction
Form 1 Hospital Eligibility and Registration Form Hospital Eligibility and Registration Form	Form and Instruction
1 Hospital Eligibility and Registration Form Attachment A - Eligibility and Registration Form - 3-3-25.docx	Form and Instruction
1 Hospital Eligibility and Registration Form Attachment A - Eligibility and Registration Form - 3-3-25.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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
Form and Instruction	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 165

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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	165	165
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	1,148	1,148

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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