GROUP PRATICE-PREPAYMENT PLAN STATEMENT OF REIMBURSEMENT COS T

ICR 197406-0938-001

OMB: 0938-0038

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
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ICR Details
0938-0038 197406-0938-001
Historical Active
HHS/CMS
GROUP PRATICE-PREPAYMENT PLAN STATEMENT OF REIMBURSEMENT COS T
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 06/18/1974
Retrieve Notice of Action (NOA) 06/18/1974
  Inventory as of this Action Requested Previously Approved
06/30/1979 06/30/1979
200 0 0
800 0 0
0 0 0



None
None


No

1
IC Title Form No. Form Name
GROUP PRATICE-PREPAYMENT PLAN STATEMENT OF REIMBURSEMENT COS T SSA-2017

  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 200 0 0 0 200 0
Annual Time Burden (Hours) 800 0 0 0 800 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
06/18/1974


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