INDEPENDENT RURAL HEALTH CLINIC COST REPORTING FORMS

ICR 198308-0938-006

OMB: 0938-0107

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
112913 Migrated
ICR Details
0938-0107 198308-0938-006
Historical Active 198212-0938-014
HHS/CMS
INDEPENDENT RURAL HEALTH CLINIC COST REPORTING FORMS
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 09/06/1983
Retrieve Notice of Action (NOA) 08/25/1983
  Inventory as of this Action Requested Previously Approved
12/31/1985 12/31/1985
524 0 0
5,652 0 0
0 0 0

THE FORM HCFA 222 WILL BE USED BY INDEPENDENT RURAL HEALTH CLINICS PARTICIPATING IN THE MEDICAID PROGRAM AT EFFECT COST SETTLEMENT FOR PROVIDING SERVICES TO MEDICARE BENEFICIARIES. CLINICS PARTICIPATING IN THE URBAN CLINICS DEMONSTRATION WILL ALSO USE THIS FOR FOR SETTLEMENT.

None
None


No

1
IC Title Form No. Form Name
INDEPENDENT RURAL HEALTH CLINIC COST REPORTING FORMS HCFA-222

  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 524 0 0 524 0 0
Annual Time Burden (Hours) 5,652 0 0 5,652 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
08/25/1983


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