CONTRACTOR'S INFORMATION COLLECTION - PROVIDER BASED PHYSICIAN FORMS

ICR 198111-0938-021

OMB: 0938-0179

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0179 198111-0938-021
Historical Active 198108-0938-003
HHS/CMS
CONTRACTOR'S INFORMATION COLLECTION - PROVIDER BASED PHYSICIAN FORMS
Revision of a currently approved collection   No
Regular
Approved without change 12/14/1981
Retrieve Notice of Action (NOA) 11/19/1981
  Inventory as of this Action Requested Previously Approved
04/30/1983 04/30/1983 10/31/1983
10,000 0 333
160,000 0 42,623
0 0 0

THESE FORMS ARE USED BY THE INTERMEDIARIES TO REVIEW BILLING ARRANGEMENTS AND TO COMPUTE THE PROVIDER AND PROFESSIONAL COMPONENTS OF PROVIDER-BASED PHYSICIANS SERVICES IN ORDER TO ALLOCATE REIMBURSEMENT BETWEEN PART A AND B TRUST FUNDS.

None
None


No

1
IC Title Form No. Form Name
CONTRACTOR'S INFORMATION COLLECTION - PROVIDER BASED PHYSICIAN FORMS HCFA-9017, HCFA-284

  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 10,000 333 0 0 9,667 0
Annual Time Burden (Hours) 160,000 42,623 0 0 117,377 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.
11/19/1981


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