Information Collection

Prepare and Transmit UB-04 Files

IC 202431 under ICR 201205-0920-009 · OMB 0920-0944.

Documents and Forms

Document Name Document Type
Form 4 Prepare and Transmit UB-04 Files Form
4 Performance of Colonoscopy in the United States Att N - NHCS Ambulatory Pretest Colonoscopy Form.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Prepare and Transmit UB-04 Files	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	4	Performance of Colonoscopy in the United States	Att N - NHCS Ambulatory Pretest Colonoscopy Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: Health Resources Utilization Statistics	FR Citation: 49 FR 37693

Number of Respondents: 47	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: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	47	47
Annual IC Time Burden (Hours)	47	47
Annual IC Cost Burden (Dollars)	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.