Information Collection

Information Collection Requirements In 405.2112, 405.2113, 405.2123, 405.2136, 405.2137, And 405.2139 - Conditions Of Coverage For Esrd Facilities

IC 113450 under ICR 198312-0938-010 · OMB unassigned.

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IC Title:

INFORMATION COLLECTION REQUIREMENTS IN 405.2112, 405.2113, 405.2123, 405.2136, 405.2137, AND 405.2139 - CONDITIONS OF COVERAGE FOR ESRD FACILITIES

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-R-50				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 0

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	0	0	0	0	0	0
Annual IC Time Burden (Hours)	0	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

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Title	Document	Date Uploaded

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