Diagnosis Related Groups (DRG) Reimbursement (Two Parts)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0017 can be found here:

Documents and Forms

Document Name Document Type
Sample Request and Statement.pdf Other-Sample Request and Statement

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Diagnosis Related Groups (DRG) Reimbursement (Two Parts)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 32 CFR 199.14

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Sample Request and Statement			Sample Request and Statement.pdf		No		Paper Only

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,993	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	4,993	-607	5,600
Annual IC Time Burden (Hours)	7,490	-910	8,400
Annual IC Cost Burden (Dollars)	232,125	-5,875	238,000

Documents for IC

Title	Document	Date Uploaded
No associated records found

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