Information Collection

Ambulatory Surgical Center Request For Certification And Survey Report Form, And The Paperwork Requirements In 42 Cfr 416.43 And 416.47

IC 113290 under ICR 198409-0938-005 · OMB 0938-0266.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0266 can be found here:

Documents and Forms

Document Name Document Type

No indexed documents/forms are available for this IC yet. A refresh has been queued.

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	AMBULATORY SURGICAL CENTER REQUEST FOR CERTIFICATION AND SURVEY REPORT FORM, AND THE PAPERWORK REQUIREMENTS IN 42 CFR 416.43 AND 416.47	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:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	HCFA-377	No	No
Form	378	No	No
Form	HCFA-R-54	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 215	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	215	-185	400
Annual IC Time Burden (Hours)	2,308	-4,192	6,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

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