Information Collection

Non-Federal Health Care Provider and Reimbursement Form

IC 147369 under ICR 199508-2900-006 · OMB 2900-0160.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0160 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Non-Federal Health Care Provider and Reimbursement Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	10-1170	No	No
Form	10-5588	No	No
Form	10-2407	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,315	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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,480	1,480
Annual IC Time Burden (Hours)	315	315
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.