HEALTH MAINTENANCE ORGANIZATION QUALIFICATION APPLICATION, HEALTH MAINTENANCE ORGANIZATION EXPANSION APPLICATION, COMPETITIVE MEDICAL PLAN APPLICATION

ICR 198409-0915-002

OMB: 0915-0065

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0915-0065 198409-0915-002
Historical Active 198306-0915-012
HHS/HSA
HEALTH MAINTENANCE ORGANIZATION QUALIFICATION APPLICATION, HEALTH MAINTENANCE ORGANIZATION EXPANSION APPLICATION, COMPETITIVE MEDICAL PLAN APPLICATION
Revision of a currently approved collection   No
Regular
Approved without change 10/18/1984
Retrieve Notice of Action (NOA) 09/18/1984
  Inventory as of this Action Requested Previously Approved
10/31/1985 10/31/1985 09/30/1984
60 0 34
6,000 0 3,400
0 0 0

THE SUBJECT FORM WILL BE USED AS AN INSTRUMENT THROUGH WHICH ENTITIES WILL APPLY AND FURNISH INFORMATION TO OHMO IN ORDER TO OBTAIN QUALIFICATION STATUS OR EXPAND THE SERVICE AREA FOR WHICH THE HMO WAS QUALIFIED.

None
None


No

1
IC Title Form No. Form Name
HEALTH MAINTENANCE ORGANIZATION QUALIFICATION APPLICATION, HEALTH MAINTENANCE ORGANIZATION EXPANSION APPLICATION, COMPETITIVE MEDICAL PLAN APPLICATION HRSA-901-1, 2, & 3

  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 60 34 0 26 0 0
Annual Time Burden (Hours) 6,000 3,400 0 2,600 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
09/18/1984


© 2024 OMB.report | Privacy Policy