Information Collection

Prepare and transmit UB-04 for Inpatient and Ambulatory

IC 186285 under ICR 201502-0920-011 · OMB 0920-0212.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0212 can be found here:

Documents and Forms

Document Name Document Type
Att P - Monthly Data Trans of UB-04 Data.doc Instruction
Att F - List of UB04 Data Elements.docx List of UB-04 Data Elements IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Prepare and transmit UB-04 for Inpatient and Ambulatory	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Instruction			Att P - Monthly Data Trans of UB-04 Data.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0167 Health Resources Utilization Statistics	FR Citation: 49 FR 37697

Number of Respondents: 481	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 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,772	3,772	2,000
Annual IC Time Burden (Hours)	5,772	3,772	2,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
List of UB-04 Data Elements	Att F - List of UB04 Data Elements.docx	02/19/2015

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