View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 0938-1197	ICR Reference No: 201211-0938-011
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Health Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424, Subpart C
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/10/2013
	Date Received in OIRA: 11/28/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2016	36 Months From Approved
Responses	988,005,045	0	0
Time Burden (Hours)	21,418,336	0	0
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	988,005,045	988,005,045
Annual Time Burden (Hours)	21,418,336	21,418,336
Annual Cost Burden (Dollars)	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection request. It is a new version of the form submitted under 0938-0999. Once both forms are approved, there will be a run-off period before only the form associated with this submission, the 1500(02-12) is acceptable for claims submission.

Something went wrong when downloading this file. If you have any questions, please send an email to risc@gsa.gov.