BILLING FORM FOR THE ALCOHOLISM SERVICES COVERAGE DEMONSTRATION

ICR 198504-0938-002

OMB: 0938-0259

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0259 198504-0938-002
Historical Active 198206-0938-007
HHS/CMS
BILLING FORM FOR THE ALCOHOLISM SERVICES COVERAGE DEMONSTRATION
Extension without change of a currently approved collection   No
Regular
Approved without change 05/07/1985
Retrieve Notice of Action (NOA) 04/09/1985
  Inventory as of this Action Requested Previously Approved
04/30/1986 04/30/1986 04/30/1985
45,000 0 45,000
6,000 0 6,000
0 0 0

ALL PARTICIPATING TREATMENT FACILITIES WILL UTILIZE THE FORM TO DOCUME SERVICES AND COSTS INCURRED IN THE TREATMENT OF ALCOHOLISM UNDER THE DEMONSTRATION. THE HCFA OFFICE OF REIMBURSEMENT WILL MAKE PAYMENT ON BASIS OF THE BILLING FORM.

None
None


No

1
IC Title Form No. Form Name
BILLING FORM FOR THE ALCOHOLISM SERVICES COVERAGE DEMONSTRATION HCFA-1480A

  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 45,000 45,000 0 0 0 0
Annual Time Burden (Hours) 6,000 6,000 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.
04/09/1985


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