FINANCIAL STATEMENT OF DEBTOR "MEDICARE"

ICR 199004-0938-003

OMB: 0938-0270

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
113308 Migrated
ICR Details
0938-0270 199004-0938-003
Historical Active 198610-0938-002
HHS/CMS
FINANCIAL STATEMENT OF DEBTOR "MEDICARE"
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 06/18/1990
Retrieve Notice of Action (NOA) 04/17/1990
Approved for use through 12/91 under the condition that the next HCFA-379 submitted for OMB approval incorporates the burden disclosure statement pursuant to 5 CFR 1320.
  Inventory as of this Action Requested Previously Approved
12/31/1991 12/31/1991
500 0 0
1,000 0 0
0 0 0

THIS FORM IS USED TO OBTAIN FINANCIAL INFORMATION NEEDED TO EVALUATE REQUESTS FROM PHYSICIANS OR SUPPLIERS TO PAY AN INDEBTEDNE UNDER AN EXTENDED REPAYMENT SCHEDULE, OR TO COMPROMISE A DEBT FOR LESS THAN THE FULL AMOUNT.

None
None


No

1
IC Title Form No. Form Name
FINANCIAL STATEMENT OF DEBTOR "MEDICARE" HCFA-379

  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 500 0 0 0 500 0
Annual Time Burden (Hours) 1,000 0 0 0 1,000 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.
04/17/1990


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