Information Collection

§418.24(c) Addendum Form Completion

IC 241789 under ICR 202604-0938-016 · OMB 0938-1067.

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Information Collection (IC) Details

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IC Title:	§418.24(c) Addendum Form Completion	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 418.24(c)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,732	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,517,250	349,202	1,168,048
Annual IC Time Burden (Hours)	255,816	63,396	192,420
Annual IC Cost Burden (Dollars)	0	0	0

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