HEALTH CARE PROGRAM VIOLATIONS NOTIFICATION FORM

ICR 199008-0990-002

OMB: 0990-0141

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
116697
Migrated
ICR Details
0990-0141 199008-0990-002
Historical Active 198904-0990-008
HHS/HHSDM
HEALTH CARE PROGRAM VIOLATIONS NOTIFICATION FORM
Revision of a currently approved collection   No
Regular
Approved without change 10/17/1990
Retrieve Notice of Action (NOA) 08/28/1990
  Inventory as of this Action Requested Previously Approved
10/31/1993 10/31/1993 11/30/1990
660 0 450
55 0 38
0 0 0

THIS INFORMATION IS NECESSARY TO NOTIFY THE OIG OF PROVIDERS ENGAGED IN MEDICAID FRAUD, TO ENABLE THE OIG TO EXCLUDE SUCH PROVIDERS FROM THE MEDICARE PROGRAM PURSUANT TO SECTION 1128, TO IMPOSE CIVIL MONETARY PENALTIES PURSUANT TO SECTION 1128A, AND TO TAKE OTHER APPROPRIATE REMEDIAL ACTION.

None
None


No

1
IC Title Form No. Form Name
HEALTH CARE PROGRAM VIOLATIONS NOTIFICATION FORM

  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 660 450 0 210 0 0
Annual Time Burden (Hours) 55 38 0 17 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.
08/28/1990


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