MEDICARE - ATTENDING PHYSICIAN'S STATEMENT AND DOCUMENTATION OF MEDICARE EMERGENCY

ICR 198905-0938-005

OMB: 0938-0023

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0023 198905-0938-005
Historical Active 198508-0938-007
HHS/CMS
MEDICARE - ATTENDING PHYSICIAN'S STATEMENT AND DOCUMENTATION OF MEDICARE EMERGENCY
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 07/17/1989
Retrieve Notice of Action (NOA) 05/18/1989
Approved for use through 1/91 under the condition that the next form submitted for OMB approval incorporates the burden disclosure statemen pursuant to 5 CFR 1320.
  Inventory as of this Action Requested Previously Approved
01/31/1991 01/31/1991
1,500 0 0
375 0 0
0 0 0

THIS FORM IS USED TO DOCUMENT THE ATTENDING PHYSICIAN'S STATEMENT THAT THE HOSPITALIZATION WAS REQUIRED DUE TO AN EMERGENCY AND GIVE CLINICAL SUPPORT FOR THE CLAIM. THIS FORM HAS BEEN IN USE FOR SOME TIME AND IS CURRENTLY APPROVED.

None
None


No

1
IC Title Form No. Form Name
MEDICARE - ATTENDING PHYSICIAN'S STATEMENT AND DOCUMENTATION OF MEDICARE EMERGENCY HCFA-1771

  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 1,500 0 0 1,500 0 0
Annual Time Burden (Hours) 375 0 0 375 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.
05/18/1989


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