Information Collection

Hospital Eligibility and Registration Form

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Hospital Eligibility and Registration Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Hospital Eligibility and Registration Form	Attachment A - Eligibility and Registration Form - 3-3-25.docx		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 %

	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

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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