Information Collection

42 CFR 485.66 and 485.66 (a)

IC 192450 under ICR 202604-0938-020 · OMB 0938-1091.

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Information Collection (IC) Details

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IC Title:	42 CFR 485.66 and 485.66 (a)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 485.66 42 CFR 485.66(a)

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: 158	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	158	-30	188
Annual IC Time Burden (Hours)	1,260	-244	1,504
Annual IC Cost Burden (Dollars)	0	0	0

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