UNIFORM BILLING CLAIM FORM

ICR 198210-1215-001

OMB: 1215-0142

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
122263 Migrated
ICR Details
1215-0142 198210-1215-001
Historical Active
DOL/ESA
UNIFORM BILLING CLAIM FORM
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 01/14/1983
Retrieve Notice of Action (NOA) 10/18/1982
This requirement imposes new reporting on hospitals. Because it is new, it is appropriate that the burden be counted accordingly and not as a correction error.
  Inventory as of this Action Requested Previously Approved
10/31/1984 10/31/1984
110,000 0 0
27,500 0 0
0 0 0

THE UNIFORM BILLING CLAIM FORM WILL ENABLE INSTITUTIONAL MEDICAL PROVIDERS TO SUBMIT CLAIMS FOR REIMBURSEMENT ON A FORM APPROVED BY THE AMERICA HOSPITAL ASSOCIATION AND MAJOR THIRD PARTY INSURANCE CARRIERS WHICH WILL ENSURE PROMPT PAYMENT OF AUTHORIZED CLAIMS.

None
None


No

1
IC Title Form No. Form Name
UNIFORM BILLING CLAIM FORM OWCP-82A &, OWCP-82B

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 110,000 0 0 110,000 0 0
Annual Time Burden (Hours) 27,500 0 0 27,500 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
10/18/1982


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