REQUEST FOR CERTIFICATION AS A SUPPLIER OF PORTABLE X-RAY SERVICES AND THE PORTABLE X-RAY SURVEY REPORT FORM

ICR 198405-0938-011

OMB: 0938-0027

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0027 198405-0938-011
Historical Active 198212-0938-006
HHS/CMS
REQUEST FOR CERTIFICATION AS A SUPPLIER OF PORTABLE X-RAY SERVICES AND THE PORTABLE X-RAY SURVEY REPORT FORM
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 07/25/1984
Retrieve Notice of Action (NOA) 05/24/1984
  Inventory as of this Action Requested Previously Approved
06/30/1986 06/30/1986
160 0 0
280 0 0
0 0 0

IN ORDER TO PARTICIPATE IN THE MEDICARE/MEDICAID PROGRAM AS A SUPPLIER OF PORTABLE-X-RAY SERVICES, SUPPLIERS MUST MEET FEDERAL CONDITIONS OF PARTICIPATION. THE CERTIFICATION FORM IS NEEDED TO DETERMINE IF SUPPLIERS MEET AT LEAST PRELIMINARY REQUIREMENTS FOR PARTICIPATION. THE SURVEY FORM IS USED TO RECORD COMPLIANCE WITH THE INDIVIDUAL CONDITIONS AND REPORT THEM TO HCFA.

None
None


No

1
IC Title Form No. Form Name
REQUEST FOR CERTIFICATION AS A SUPPLIER OF PORTABLE X-RAY SERVICES AND THE PORTABLE X-RAY SURVEY REPORT FORM HCFA-1880, 1882

  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 160 0 0 0 160 0
Annual Time Burden (Hours) 280 0 0 0 280 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
05/24/1984


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