MEDICARE - INTERMEDIARY REQUEST TO SKILLED NURSING FACILITIES FOR MEDICAL INFORMATION ON CLAIMS TO BE PROCESSED

ICR 199005-0938-002

OMB: 0938-0223

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0223 199005-0938-002
Historical Active 198803-0938-003
HHS/CMS
MEDICARE - INTERMEDIARY REQUEST TO SKILLED NURSING FACILITIES FOR MEDICAL INFORMATION ON CLAIMS TO BE PROCESSED
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 08/01/1990
Retrieve Notice of Action (NOA) 05/01/1990
  Inventory as of this Action Requested Previously Approved
07/31/1991 07/31/1991
244,250 0 0
122,125 0 0
0 0 0

THIS INFORMATION IS USED BY THE FISCAL INTERMEDIARIES TO DETERMINE MEDICAL COVERAGE FOR SKILLED NURSING FACILITIES. THE MEDICAL INFORMATION FORM DESCRIBES THE PATIENT'S CONDITION. THESE FORMS ARE SUBMITTED WITH THE CLAIMS AND AS REQUESTED

None
None


No

1
IC Title Form No. Form Name
MEDICARE - INTERMEDIARY REQUEST TO SKILLED NURSING FACILITIES FOR MEDICAL INFORMATION ON CLAIMS TO BE PROCESSED HCFA 9031

  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 244,250 0 0 244,250 0 0
Annual Time Burden (Hours) 122,125 0 0 122,125 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.
05/01/1990


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