OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

COVID–19 Provider Relief Programs Application and Attestation Portal, and Claims Reimbursement Submission Activities

OMB 0906-0069 · HHS/HRSA.

OMB 0906-0069

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form 4 UIP_Portal_Screenshots.docxForm
Form 4 Uninsured Provider (UIP) ApplicationForm
Form 3 CAF Application Screenshots.pdfForm
Form 3 Coverage Assistance Fund (CAF) ApplicationForm
Form 2 PRF and ARP-R Attestation and Application Screenshots.pptxForm
Form 2 PRF and ARP-R Application PortalForm
Form 1 PRF and ARP-R Attestation and Application Screenshots.pptxForm
Form 1 Provider Relief Fund (PRF) and American Rescue Plan Act Rural (ARP-R) Attestation PortalForm
Supporting Statement A.docxSupporting Statement A
Uninsured Provider (UIP) Application Form
Uninsured Provider (UIP) Application Form
Coverage Assistance Fund (CAF) Application Form
Coverage Assistance Fund (CAF) Application Form
PRF and ARP-R Application Portal Form
PRF and ARP-R Application Portal Form
Provider Relief Fund (PRF) and American Rescue Plan Act Rural (ARP-R) Attestation Portal Form
Provider Relief Fund (PRF) and American Rescue Plan Act Rural (ARP-R) Attestation Portal Form

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202201-0906-002 New collection (Request for a new OMB Control Number) 2022-01-21 Approved without change