HOSPITAL REQUEST FOR CERTIFICATION IN THE MEDICARE/MEDICAID PROGRAM

ICR 199012-0938-010

OMB: 0938-0380

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
0938-0380 199012-0938-010
Historical Active 199006-0938-001
HHS/CMS
HOSPITAL REQUEST FOR CERTIFICATION IN THE MEDICARE/MEDICAID PROGRAM
Revision of a currently approved collection   No
Regular
Approved without change 03/14/1991
Retrieve Notice of Action (NOA) 12/14/1990
  Inventory as of this Action Requested Previously Approved
03/31/1994 03/31/1994 08/31/1992
1,984 0 1,984
496 0 496
0 0 0

SECTION 1861 OF THE SOCIAL SECURITY ACT REQUIRES HOSPITALS TO BE CERTIFIED TO PARTICIPATE IN THE MEDICARE/MEDICAID PROGRAM. THESE PROVIDERS MUST COMPLETE THE HOSPITAL REQUEST FOR CERTIFICATION ON THE MEDICARE/MEDICAID PROGRAM FORM WHICH CONCERNS INFORMATION COLLECTI REQUIREMENTS AND THERE USES.

None
None


No

1
IC Title Form No. Form Name
HOSPITAL REQUEST FOR CERTIFICATION IN THE MEDICARE/MEDICAID PROGRAM HCFA-1514

  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 1,984 1,984 0 0 0 0
Annual Time Burden (Hours) 496 496 0 0 0 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.
12/14/1990


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