View Information Collection (IC)

View Information Collection (IC)

IC Title:	Quarterly Transmission of UB -04 Data	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Other-WORD			Att H Quarterly Transmission of UB-04 Data.doc		Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0167 Health Resource Utilization Statistics	FR Citation: 49 FR 37697

Number of Respondents: 500	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 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	2,000	0	0	0	0	2,000
Annual IC Time Burden (Hours)	2,000	0	0	0	0	2,000
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Att L List of UB04 Data Elements	Att L List of UB04 Data Elements.docx	01/05/2011

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