Information Collection

Enrollment Process for Qualified Individuals (§ 156.1230)

IC 230943 under ICR 202512-0938-018 · OMB 0938-1353.

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Information Collection (IC) Details

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IC Title:	Enrollment Process for Qualified Individuals (§ 156.1230)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 156.1230

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: 88	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: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	88	13	75
Annual IC Time Burden (Hours)	1,320	195	1,125
Annual IC Cost Burden (Dollars)	0	0	0

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