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 166219 under ICR 198509-0938-021 · OMB 0938-0266.

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Documents and Forms

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Information Collection (IC) Details

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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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	215	0	215
Annual IC Time Burden (Hours)	2,431	123	2,308
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.