DETERMINING LEVEL OF CARE REQUIRED BY PATIENT IN SKILLED NURSING FACILITY

ICR 198305-0938-017

OMB: 0938-0031

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0031 198305-0938-017
Historical Active 197808-0938-005
HHS/CMS
DETERMINING LEVEL OF CARE REQUIRED BY PATIENT IN SKILLED NURSING FACILITY
No material or nonsubstantive change to a currently approved collection   No
Emergency 05/18/1983
Approved with change 05/18/1983
Retrieve Notice of Action (NOA) 05/18/1983
  Inventory as of this Action Requested Previously Approved
10/31/1983 10/31/1983 10/31/1983
16,440 0 26,000
4,110 0 6,500
0 0 0

THE FORM FURNISHES INFORMATION REGARDING THE MEDICAL CONDITION OF THE PATIENT, THE EXPECTED SERVICES TO BE FURNISHED, AND THE PROVIDER'S ESTIMATE OF MEDICARE COVERAGE. THIS IS REQUIRED TO DETERMINE BENEFITS TO BE PAID UNDER MEDICARE.

None
None


No

1
IC Title Form No. Form Name
DETERMINING LEVEL OF CARE REQUIRED BY PATIENT IN SKILLED NURSING FACILITY HCFA-1922

  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 16,440 26,000 0 -9,560 0 0
Annual Time Burden (Hours) 4,110 6,500 0 -2,390 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes

$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.
05/18/1983


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