View Information Collection (IC)

View Information Collection (IC)

IC Title:	Health Insurance Cost Sharing Collection- 2020	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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
Form and Instruction	107a	Attachment 107a.Protocol A (Medicare)	Attachment 107a.Protocol A (Medicare)_final OMB_v2.docx		Yes	Yes	Fillable Fileable
Form and Instruction	107b	Attachment 107b.Protocol B (Employer)	Attachment 107b.Protocol B (Employer)_final OMB_v2.docx		Yes	Yes	Fillable Fileable
Form and Instruction	107c	Attachment 107c.Protocol C (Private with Medicare)_	Attachment 107c.Protocol C (Private with Medicare)_final OMB_v2.docx		Yes	Yes	Fillable Fileable
Form and Instruction	107d	Attachment 107d.Protocol D (Other)	Attachment 107d.Protocol D (Other)_final OMB_v2.docx		Yes	Yes	Fillable Fileable

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: 6,258	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	8,135	0	0	0	0	8,135
Annual IC Time Burden (Hours)	6,101	0	0	0	0	6,101
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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