REQUESTS FOR MEDICARE PAYMENT BY MUNICIPAL HEALTH SERVICES PROGRAM (MHSP) CLINICS

ICR 198603-0938-002

OMB: 0938-0091

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
0938-0091 198603-0938-002
Historical Active 198405-0938-005
HHS/CMS
REQUESTS FOR MEDICARE PAYMENT BY MUNICIPAL HEALTH SERVICES PROGRAM (MHSP) CLINICS
Revision of a currently approved collection   No
Regular
Approved without change 04/30/1986
Retrieve Notice of Action (NOA) 03/05/1986
  Inventory as of this Action Requested Previously Approved
05/31/1989 05/31/1989 03/31/1986
73,605 0 126,008
11,777 0 18,901
0 0 0

THE MUNICIPAL HEALTH SERVICES CLINIC BILLING FORMS (HCFA-127 AND HCFA-127A) ALLOWS FOR THE 15 PARTICIPATING CLINICS TO BE REIMBURSED FOR SERVICES THEY PROVIDED TO MEDICARE BENEFICIARIES. HCFA-127 "REQUEST FOR MEDICARE PAYMENT BY MHSP CLINIC" PERMITS CITES PARTICIPATING IN THE MHSP TO RECEIVE CORRECT AND TIMELY REIMBURSEMENT AND HCFA-127A "TRANSMITTAL OF REQUEST FOR MEDICARE PAYMENTS BY MHSP CLINIC" EXPEDITES THE ROUTING AND PAYMENT OF BILLS.

None
None


No

1
IC Title Form No. Form Name
REQUESTS FOR MEDICARE PAYMENT BY MUNICIPAL HEALTH SERVICES PROGRAM (MHSP) CLINICS HCFA 127&, 127A

  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 73,605 126,008 0 0 -52,403 0
Annual Time Burden (Hours) 11,777 18,901 0 0 -7,124 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.
03/05/1986


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