Information Collection

Section 493.1359- 493.1489-1491

IC 264337 under ICR 202606-0938-021 · OMB 0938-0612.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
2024.01.29_CMS3326F Crosswalk with Dtags and IGs_DRAFT_pk.xlsx Crosswalk	IC Document
2024.01.29_CMS3326F-Crosswalk w D-tags_DRAFT_PK.docx Crosswalk	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 493.1359- 493.1489-1491

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 34,082

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	34,082	34,082
Annual IC Time Burden (Hours)	238,574	238,574
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk		06/03/2024
Crosswalk		06/03/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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