Prepare and transmit UB-04 or State File for Inpatient and Ambulatory

National Hospital Care Survey

⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0212 Prepare and transmit UB-04 or State File for Inpatient and Ambulatory Form and Instruction
0920-0212 Att K - Monthly Data Transmission of UB-04 Data Att K - Monthly Data Transmission of UB-04 Data.docx Form and Instruction
0920-0212 Att K - Monthly Data Transmission of UB-04 Data Att K - Monthly Data Transmission of UB-04 Data.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Prepare and transmit UB-04 or State File for Inpatient and Ambulatory	Agency IC Tracking Number:	0920-0212

Is this a Common Form? No		IC Status: Modified

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
Form and Instruction	0920-0212	Att K - Monthly Data Transmission of UB-04 Data	Att K - Monthly Data Transmission of UB-04 Data.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0167 Health Resources Utilization Statistics	FR Citation: 49 FR 37693

Number of Respondents: 408	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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4,896	108	4,788
Annual IC Time Burden (Hours)	4,896	108	4,788
Annual IC Cost Burden (Dollars)	0	0	0

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.