View Information Collection (IC)

View Information Collection (IC)

IC Title:	Information Collection Requirements Referenced in HIPAA for the Group Market, Supporting Regulations 45 CFR 146, and forms/instructions (CMS-R-206)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 146.111 45 CFR 146.115 45 CFR 146.117 45 CFR 146.150 45 CFR 146.152 45 CFR 146.160 45 CFR 146.180

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Letter			R-206 HIPAA letter Version 2.doc		Yes	Yes	Paper Only
Other-Letter			R-206 NMHPA letter.doc		Yes	Yes	Paper Only
Other-Letter			R-206 WHCRA letter.doc		Yes	Yes	Paper 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: 7,400	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	36,902,550	0	0	-99,667	0	37,002,217
Annual IC Time Burden (Hours)	2,918,783	0	0	2,472,104	0	446,679
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
R-206 Opt Out Model Language	R-206 Opt Out Model Language.doc	06/26/2009
R-206 Respondents Burden Hours Version2	R-206 Respondents Burden Hours Version2.xls	06/26/2009

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