UNIFORM BILL QUESTIONNAIRE

ICR 198006-0938-001

OMB: 0938-0117

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
112933 Migrated
ICR Details
0938-0117 198006-0938-001
Historical Active 197903-0938-001
HHS/CMS
UNIFORM BILL QUESTIONNAIRE
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 07/01/1980
Retrieve Notice of Action (NOA) 06/02/1980
  Inventory as of this Action Requested Previously Approved
10/31/1980 10/31/1980
500 0 0
750 0 0
0 0 0

THIS IS A ONE-TIME SURVEY OF A SAMPLE OF HOSPITALS EXPERIMENTING WITH UNIFORM BILLS.

None
None


No

1
IC Title Form No. Form Name
UNIFORM BILL QUESTIONNAIRE HCFA-79, HCFA-79T

  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 500 0 0 0 500 0
Annual Time Burden (Hours) 750 0 0 0 750 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.
06/02/1980


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