View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

FSASC Prepare and Transmit UB-40
 
No Removed
 
Voluntary
 

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

Health Immunization Management

Health Resources Utilization Statistics  49 FR 37693

250 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 0 0 -1,000 0 0 1,000
Annual IC Time Burden (Hours) 0 0 -1,000 0 0 1,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.