REQUEST FOR CERTIFICATION AS A SUPPLIER OF PORTABLE X-RAY SERVICES UNDER THE MEDICARE AND/OR PROGRAM

ICR 198006-0938-004

OMB: 0938-0027

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0027 198006-0938-004
Historical Active 197803-0938-018
HHS/CMS
REQUEST FOR CERTIFICATION AS A SUPPLIER OF PORTABLE X-RAY SERVICES UNDER THE MEDICARE AND/OR PROGRAM
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 09/24/1980
Retrieve Notice of Action (NOA) 06/09/1980
  Inventory as of this Action Requested Previously Approved
12/31/1980 12/31/1980
300 0 0
1,600 0 0
0 0 0

INFORMATION FROM THIS FORM IS USED TO DETERMINE WHETHER A SUPPLIER OF PORTABLE X-RAY SERVICES MEETS THE REQUIREMENTS FOR PARTICIPATION IN THE MEDICARE PROGRAM. THE INFORMATION IS ALSO USED TO PRODUCE REPORTS ON PROGRAM ACTIVITIES AND TO EVALUATE THE PERFORMANCE OF STATE AGENCIES.

None
None


No

1
IC Title Form No. Form Name
REQUEST FOR CERTIFICATION AS A SUPPLIER OF PORTABLE X-RAY SERVICES UNDER THE MEDICARE AND/OR PROGRAM HCFA-1882

  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 300 0 0 0 300 0
Annual Time Burden (Hours) 1,600 0 0 0 1,600 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.
06/09/1980


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