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Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424 Subpart C

IC 8856 under ICR 201211-0938-010 · OMB 0938-0999.

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Form and Instruction
Form and Instruction
Form and Instruction
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Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424 Subpart C
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 424 Subpart C

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-1500(08-05) Health Insurance Claim Form CMS1500(08-05).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-1490-S PATIENT'S REQUEST FOR MEDICAL PAYMENT CMS1490S English.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

1,448,346 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   86 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 988,005,045 0 0 17,830,785 970,174,260 0
Annual IC Time Burden (Hours) 21,481,336 0 0 -11,586,421 33,067,757 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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