INFORMTION COLLECTION REQUIREMENTS IN BERC-329-P, PAYMENT ADJUSTMENT FOR SOLE COMMUNITY HOSPITAL, 42 CFR-412.92(B) NPRM

ICR 198605-0938-005

OMB: 0938-0477

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0477 198605-0938-005
Historical Active
HHS/CMS
INFORMTION COLLECTION REQUIREMENTS IN BERC-329-P, PAYMENT ADJUSTMENT FOR SOLE COMMUNITY HOSPITAL, 42 CFR-412.92(B) NPRM
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 07/06/1986
Retrieve Notice of Action (NOA) 05/06/1986
  Inventory as of this Action Requested Previously Approved
06/30/1989 06/30/1989
1 0 0
1 0 0
0 0 0

WE ARE REQUESTING APPROVAL OF THE INFORMATION COLLECTION REQUIREMENTS IN THIS PROPOSED REGULATION. TO QUALIFY FOR AN ADJUSTMENT TO ITS HOSPITAL-SPECIFIC RATE, A SOLE COMMUNITY HOSPITAL MUST SUBMIT DOCUMENTATION TO THE INTERMEDIARY DEMONSTRATING THE JUSTIFICATION FOR THE OCCURRENCE, AND THE AMOUNT OF THE DISTORTION THA RESULTS FROM THE SPECIFIED EVENT.

None
None


No

1
IC Title Form No. Form Name
INFORMTION COLLECTION REQUIREMENTS IN BERC-329-P, PAYMENT ADJUSTMENT FOR SOLE COMMUNITY HOSPITAL, 42 CFR-412.92(B) NPRM HCFA-R-79

  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 1 0 0 1 0 0
Annual Time Burden (Hours) 1 0 0 1 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
05/06/1986


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