HOSPITAL REQUEST FOR CERTIFICATION

ICR 198503-0938-031

OMB: 0938-0380

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
166279 Migrated
ICR Details
0938-0380 198503-0938-031
Historical Active 198502-0938-014
HHS/CMS
HOSPITAL REQUEST FOR CERTIFICATION
No material or nonsubstantive change to a currently approved collection   No
Emergency 03/04/1985
Approved with change 03/04/1985
Retrieve Notice of Action (NOA) 03/04/1985
  Inventory as of this Action Requested Previously Approved
09/30/1987 09/30/1987 09/30/1987
53 0 53
496 0 496
0 0 0

THIS CERTIFICATION FORM IS A FACILITY IDENTIFICATION AND SCREENING FORM USED TO INITIATE THE CERTIFICATION PROCESS, IF A PROVID MEETS THESE PRELIMINARY REQUIREMENTS, A SURVEY IS SCHEDULED TO SEE IF THE PROVIDER COMPLIES WITH THE CONDITIONS OF PARTICIPATION REQUIRED BY THE MEDICARE PROGRAM.

None
None


No

1
IC Title Form No. Form Name
HOSPITAL REQUEST FOR CERTIFICATION HCFA-1514

  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 53 53 0 0 0 0
Annual Time Burden (Hours) 496 496 0 0 0 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.
03/04/1985


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