Information Collection

Request For Approval/advance Approval As A Supplier Of Esrd Services In The Medicare Program

IC 112675 under ICR 197904-0938-001 · OMB 0938-0055.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0055 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	REQUEST FOR APPROVAL/ADVANCE APPROVAL AS A SUPPLIER OF ESRD SERVICES IN THE MEDICARE PROGRAM	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-3402,				No	No
Form	HCFA-3403				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 0	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-1,000	0	1,000
Annual IC Time Burden (Hours)	0	-366	366
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

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