Information Collection

Authorization And Invoice For Medical And Hospital Services

IC 174663 under ICR 198610-2900-010 · OMB 2900-0339.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	AUTHORIZATION AND INVOICE FOR MEDICAL AND HOSPITAL SERVICES	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

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	10-7078				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 252,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	252,000	252,000
Annual IC Time Burden (Hours)	10,080	10,080
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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