MIGRANT HOSPITALIZATION PROGRAM REFERRAL FORM

ICR 197902-0915-002

OMB: 0915-0001

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
110022 Migrated
ICR Details
0915-0001 197902-0915-002
Historical Active 197712-0915-001
HHS/HSA
MIGRANT HOSPITALIZATION PROGRAM REFERRAL FORM
Reinstatement without change of a previously approved collection   No
Regular
Approved without change 02/28/1979
Retrieve Notice of Action (NOA) 02/02/1979
  Inventory as of this Action Requested Previously Approved
01/31/1981 01/31/1981
3,000 0 0
480 0 0
0 0 0

PURPOSES OF THE FORM: A RECORD OF REFERRAL; HOSITALS USE AS AUTHORIZATION TO PROVIDE INPATIENT SERVICES; HCFA/BHI USES FOR STATISTICAL DATA AND ALSO AS THE AUTHORIZATION TO REIMBURSE HOSPITALS FOR SERVICES PROVIDED.

None
None


No

1
IC Title Form No. Form Name
MIGRANT HOSPITALIZATION PROGRAM REFERRAL FORM HSA-50

  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 3,000 0 0 0 3,000 0
Annual Time Burden (Hours) 480 0 0 0 480 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.
02/02/1979


© 2024 OMB.report | Privacy Policy