Information Collection

FSASC Prepare and Transmit UB-40

IC 205649 under ICR 201511-0920-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Attachment W- FSASC Quarterly Data Transmission of UB-04 Data.doc Instruction
Attachment Q- List of UB04 Data Elements.docx Att Q - UB-04 Data Elements IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	FSASC Prepare and Transmit UB-40	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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			Attachment W- FSASC Quarterly Data Transmission of UB-04 Data.doc		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: 250	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 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-1,000	1,000
Annual IC Time Burden (Hours)	-1,000	1,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att Q - UB-04 Data Elements	Attachment Q- List of UB04 Data Elements.docx	01/31/2013

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