Information Collection

Information Collection Requirements In 405.2111, 405, 2114, 405.2112, 405.2113, 405.2123, 405.2134, 405.2135, 405.2136, 405.2137 & 405.2139--conditions Of Coverage For Fsrd Fac.

IC 113624 under ICR 198601-0938-004 · OMB 0938-0386.

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Information Collection (IC) Details

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IC Title:	INFORMATION COLLECTION REQUIREMENTS IN 405.2111, 405, 2114, 405.2112, 405.2113, 405.2123, 405.2134, 405.2135, 405.2136, 405.2137 & 405.2139--CONDITIONS OF COVERAGE FOR FSRD FAC.	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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-R-52				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,350	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,350	1,350
Annual IC Time Burden (Hours)	72,312	72,312
Annual IC Cost Burden (Dollars)	0	0

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