SURVEY OF MUNICIPAL HOSPITAL SERVICES

ICR 197906-0938-002

OMB: 0938-0091

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
112844 Migrated
ICR Details
0938-0091 197906-0938-002
Historical Active
HHS/CMS
SURVEY OF MUNICIPAL HOSPITAL SERVICES
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 07/02/1979
Retrieve Notice of Action (NOA) 06/12/1979
  Inventory as of this Action Requested Previously Approved
06/30/1981 06/30/1981
75,000 0 0
37,500 0 0
0 0 0

THESE BILLING FORMS WILL BE USED BY PROVIDERS PARTICIPATING IN THE MUNICIPAL HEALTH SERVICES PROGRAM TO SUBMIT TO HCFA AND TO BILL MEDICARE FOR SERVICES PROVIDED TO MEDICARE BENEFICIARIES. BECAUSE OF THE EXPANDED SERVICES AND REIMBURSEMENT REQUIREMENTS UNDER THIS DEMONSTRATION, DETAILED UTILIZATION DATA IS NEEDED WHICH CANNOT BE OBTAINED CONVENIENTLY ON OTHER MEDICARE BILLING FORMS. THE DATA COLLECTED WILL BE USED TO VERIFY THAT ALL CLAIMS THAT HAVE BEE

None
None


No

1
IC Title Form No. Form Name
SURVEY OF MUNICIPAL HOSPITAL SERVICES HCFA-127,, 127C

  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 75,000 0 0 0 75,000 0
Annual Time Burden (Hours) 37,500 0 0 0 37,500 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.
06/12/1979


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