View Information Collection (IC)

View Information Collection (IC)

IC Title:	FSASC Prepare and Transmit UB-40	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Instruction			Attachment W- FSASC Quarterly Data Transmission of UB-04 Data.doc		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: Health Resources Utilization Statistics	FR Citation: 49 FR 37693

Number of Respondents: 250	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: 100 %

	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	1,000	0	1,000	0	0	0
Annual IC Time Burden (Hours)	1,000	0	1,000	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Att Q - UB-04 Data Elements	Attachment Q- List of UB04 Data Elements.docx	01/31/2013

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