HCFA FORMS AND MANUAL ORDER

ICR 198802-0938-001

OMB: 0938-0356

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
113513 Migrated
ICR Details
0938-0356 198802-0938-001
Historical Active 198501-0938-009
HHS/CMS
HCFA FORMS AND MANUAL ORDER
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 04/05/1988
Retrieve Notice of Action (NOA) 02/05/1988
  Inventory as of this Action Requested Previously Approved
04/30/1991 04/30/1991
753 0 0
2,559 0 0
0 0 0

THE HCFA-1961 WILL BE USED BY MEDICARE INTERMEDIARES, CARRIERS, STATE AGENCIES AND ESRD NETWORKS TO ORDER MEDICARE FORMS AND PROGRAM MANUAL FROM THE HEALTH CARE FINANCING ADMINISTRATION.

None
None


No

1
IC Title Form No. Form Name
HCFA FORMS AND MANUAL ORDER HCFA-1961

  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 753 0 0 0 753 0
Annual Time Burden (Hours) 2,559 0 0 0 2,559 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.
02/05/1988


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