BILLING FORMS FORM MEDICARE/MEDICAID HOSPICE DEMONSTRATION

ICR 198407-0938-002

OMB: 0938-0150

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0150 198407-0938-002
Historical Active 198402-0938-006
HHS/CMS
BILLING FORMS FORM MEDICARE/MEDICAID HOSPICE DEMONSTRATION
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 08/13/1984
Retrieve Notice of Action (NOA) 07/18/1984
  Inventory as of this Action Requested Previously Approved
03/31/1986 03/31/1986
1,260 0 0
8,970 0 0
0 0 0

TO ENSURE PROPER PAYMENT FOR THE MEDICARE/MEDICAID HOSPICE DEMONSTRATI FOR SERVICES PROVIDED TO THE BENEFICIARIES BY THE 26 HOSPICE ORGANIZATIONS SELECTED TO PARTICIPATE. USES: THE BILLING FORMS WILL B USED FOR SERVICES COVERED UNDER THIS DEMONSTRATION ON THE BASIS OF REASONABLE COST SUBJECT TO RETROSPECTIVE COST REIMBURSEMENT.

None
None


No

1
IC Title Form No. Form Name
BILLING FORMS FORM MEDICARE/MEDICAID HOSPICE DEMONSTRATION HCFA-245, 246

  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 1,260 0 0 0 1,260 0
Annual Time Burden (Hours) 8,970 0 0 0 8,970 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.
07/18/1984


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