COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY ELIGIBILITY & SURVEY FORMS AND INFORMATION COLLECTION REQUIREMENTS IN 42 CFR 488.56, 488.58, 488.60, 488.64, 488.66 AND 405.262

ICR 198710-0938-005

OMB: 0938-0267

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0267 198710-0938-005
Historical Active 198509-0938-020
HHS/CMS
COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY ELIGIBILITY & SURVEY FORMS AND INFORMATION COLLECTION REQUIREMENTS IN 42 CFR 488.56, 488.58, 488.60, 488.64, 488.66 AND 405.262
Revision of a currently approved collection   No
Regular
Approved without change 01/18/1988
Retrieve Notice of Action (NOA) 10/29/1987
  Inventory as of this Action Requested Previously Approved
06/30/1988 06/30/1988 11/30/1987
162 0 100
77,540 0 47,185
0 0 0

IN ORDER TO PARTICIPATE IN THE MEDICARE/MEDICAID PROGRAM AS A CORF PROVIDERS MUST MEET FEDERAL CONDITIONS FOR PARTICIPATION. THE CERTIFICATION FORM IS NEEDED TO DETERMINE IF PROVIDERS MEET AT LEAST PRELIMINARY REQUIREMENT THE SURVEY FORM IS USED TO RECORD PROVIDER COMPLIANCE WITH THE INDIVIDUAL CONDITIONS AND REPORT IT TO HCFA.

None
None


No

  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 162 100 0 0 62 0
Annual Time Burden (Hours) 77,540 47,185 0 0 30,355 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.
10/29/1987


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