IN ORDER TO PARTICIPATE IN THE
MEDICARE PROGRAM AS A PHYSICAL THERAPIS IN INDEPENDENT PRACTICE IT
IS REQUIRED THAT PROVIDERS OF THESE SERVICE MEET CERTAIN HEALTH AND
SAFETY STANDARDS. THIS CERTIFICATION FORM IS UTILIZED BY STATE
AGENCY SURVEYORS IN DETERMINING IF MINIMUM STANDARDS ARE MET.
REVISE IT TO MEET THEIR SPECIAL NEEDS.
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.