View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Service Level Data Collection for Initial Determinations and Appeals	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.516 (a) 42 CFR 422.514 (a) 42 CFR 423.505(f)(2) 42 CFR 422.505(f)(3) 42 CFR 422.504(f)(2)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Service Level Data Collection_508.docx		Yes	Yes	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 728	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	2,912	0	2,912	0	0	0
Annual IC Time Burden (Hours)	1,456	0	1,456	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Track Change - Service Level Data Collection	Service Level Data Collection_508redline.pdf	09/09/2025

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