Information Collection

Request For Exception To Composite Rate For Outpatient Dialysis Services, Provider Reimbursement Manual, Section 2721, 2722, 2725

IC 113372 under ICR 198306-0938-003 · OMB 0938-0296.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	REQUEST FOR EXCEPTION TO COMPOSITE RATE FOR OUTPATIENT DIALYSIS SERVICES, PROVIDER REIMBURSEMENT MANUAL, SECTION 2721, 2722, 2725	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-9044				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	24,000	24,000
Annual IC Cost Burden (Dollars)	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.