UNCOMPENSATED SERVICES ASSURANCE REPORT

Forms and Documents

Document	Type	Status	Availability

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Collection	Type	Status	Form
110241	UNCOMPENSATED SERVICES ASSURANCE REPORT	Form	Migrated

ICR Details

OMB Control No: 0915-0077	ICR Reference No: 198309-0915-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: UNCOMPENSATED SERVICES ASSURANCE REPORT
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/23/1983
	Date Received in OIRA: 09/27/1983
Terms of Clearance: THIS COLLECTION, ABSENT PART C AND PART D, IS APPROVED FOR USE PROVIDI THE FOLLOWING REVISIONS ARE MADE: 1.THE FOLLOWING QUESTIONS SHOULD BE ADDED: A.DOES YOUR INSTITUTION MAINTAIN ACCOUNTS WHICH CLEARLY SEGREGATE UNCOMPENSATED SERVICES FROM OTHER ACCOUNTS B.DOES YOUR INSTITUTION MAINTAIN RECORDS IN ACCORDANCE WITH THE REQUIREMENT OUTLINED IN 124.510[B][2] C.IN COMPUTING UNCOMPENSATED SERVICES PROVIDED, HAS YOUR INSTITUTION INCLUDED AMOUNTS DESCRIBED IN THE FOLLOWING REGULATORY CITATIONS: 124.509[a],124.509[b],124.509[c],124.509[d] 2.QUESTION 39 SHOULD BE REVISED TO INCORPORATE A NEW 39a WHICH SHOULD READ...HAS THE FACILITY BEEN REQUIRED TO ADOPT AN ALLOCATION PLAN. THE OLD QUESTIONS 39a and 39b SHOULD BECOME 39b AND 39c RESPECTFULLY. IT IS OMBs UNDERSTANDING THAT DEFINITIONAL AND REPORTING INCONSISTENCI EXIST BETWEEN PART C AND PART D OF THIS COLLECTION AND THE HOSPITAL COST REPORT. PHS SHOULD REVIEW THESE SECTIONS WITH THE CHIEF, COST REPORTS AND AUDIT POLICY BRANCH/BUREAU OF ELIGIBILITY, REIMBURSE MENT AND COVERAGE POLICY/HCFA. BY 2/1/84, HHS SHALL SEND TO OMB REVISE PARTS C AND D AND A LETTER ASSERTING THAT CONSISTENCY BETWEEN THE PHS AND THE HCFA COLLECTION HAS BEEN ACHIEVED.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/1985	08/31/1985
Responses	1,525	0	0
Time Burden (Hours)	1,586,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: HEALTH CARE FACILITIES WHICH HAVE RECEIVED FUNDS UNDER TITLES VI AND XVI OF THE PHS ACT ARE REQUIRED TO PROVIDE A PRESCRIBED AMOUNT OF CARE TO PERSONS UNABLE TO PAY AND TO SUBMIT TO THE SECRETARY DATA AND INFORMATION WHICH REASONABLY DEMONSTRATES COMPLIANCE WITH THIS REQUIREMENT.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
UNCOMPENSATED SERVICES ASSURANCE REPORT	HRSA-710

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ICR Summary of Burden

	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	1,525	0	0	0	1,525	0
Annual Time Burden (Hours)	1,586,000	0	0	0	1,586,000	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 09/27/1983

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