MEDICARE REQUEST FOR APPROVAL AS A SUPPLIER OF ESRD SERVICES IN THE MEDICARE PROGRAM

ICR 198605-0938-013

OMB: 0938-0055

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
0938-0055 198605-0938-013
Historical Active 198406-0938-002
HHS/CMS
MEDICARE REQUEST FOR APPROVAL AS A SUPPLIER OF ESRD SERVICES IN THE MEDICARE PROGRAM
Revision of a currently approved collection   No
Regular
Approved without change 07/17/1986
Retrieve Notice of Action (NOA) 05/16/1986
  Inventory as of this Action Requested Previously Approved
07/31/1989 07/31/1989 07/31/1986
700 0 650
816 0 758
0 0 0

IN ORDER TO PARTICIPATE IN THE MEDICARE PROGRAM AS A SUPPLIER OF ESRD SERVICES, A FACILITY MUST REQUEST APPROVAL AND MEET CERTAIN HEALTH AND SAFETY STANDARDS. THIS APPLICATION FORM INITIATES THE CERTIFICATION PROCESS. THE FORM ALSO PROMOTES DATA COLLECTION FOR USE IN THE MEDICARE/MEDICAID AUTOMATED CERTIFICATION SYSTEM.

None
None


No

1
IC Title Form No. Form Name
MEDICARE REQUEST FOR APPROVAL AS A SUPPLIER OF ESRD SERVICES IN THE MEDICARE PROGRAM HCFA-3402

  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 700 650 0 0 50 0
Annual Time Burden (Hours) 816 758 0 0 58 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.
05/16/1986


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