PHYSICAL THERAPIST IN INDEPENDENT PRACTICE SURVEY REPORT

ICR 198203-0938-014

OMB: 0938-0071

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
166143 Migrated
ICR Details
0938-0071 198203-0938-014
Historical Active 197904-0938-002
HHS/CMS
PHYSICAL THERAPIST IN INDEPENDENT PRACTICE SURVEY REPORT
No material or nonsubstantive change to a currently approved collection   No
Emergency 03/30/1982
Approved with change 03/30/1982
Retrieve Notice of Action (NOA) 03/30/1982
  Inventory as of this Action Requested Previously Approved
05/31/1984 05/31/1984 05/31/1984
700 0 700
3,600 0 1,400
0 0 0

SECTION 1861(P)(4) OF THE SOCIAL SECURITY ACT REQUIRES THAT TO PARTICIPATE AS A SUPPLIER OF OUTPATIENT PHYSICAL THERAPY SERVICES, AN INDIVIDUAL MUST MEET STATE LICENSURE AND OTHER REQUIREMENTS. THIS FORM IS COMPLETED BY INDIVIDUALS WISHING TO PARTICIPATE IN THE MEDICARE/MEDICAID PROGRAM AS A SUPPLIER OF SERVICES. REQUIREMENTS FOR PARTICIPATION ARE SPECIFIED IN 42 CFR 405.1718-1726.

None
None


No

1
IC Title Form No. Form Name
PHYSICAL THERAPIST IN INDEPENDENT PRACTICE SURVEY REPORT HCFA-3042

  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 700 700 0 0 0 0
Annual Time Burden (Hours) 3,600 1,400 0 0 2,200 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.
03/30/1982


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