INFORMATION COLLECTION REQUIREMENTS AT 42 CFR 411.54(C)(1) ITEMIZED STATEMENT OF HOSPITAL CHARGES

ICR 199111-0938-002

OMB: 0938-0558

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0558 199111-0938-002
Historical Active 198911-0938-003
HHS/CMS
INFORMATION COLLECTION REQUIREMENTS AT 42 CFR 411.54(C)(1) ITEMIZED STATEMENT OF HOSPITAL CHARGES
Extension without change of a currently approved collection   No
Regular
Approved without change 01/29/1992
Retrieve Notice of Action (NOA) 11/12/1991
  Inventory as of this Action Requested Previously Approved
01/31/1995 01/31/1995 01/31/1992
1 0 1
1 0 1
0 0 0

UNDER THE PROVISIONS CONTAINED AS PART OF 42 CFR SECTION 411.54(C)(1) HOSPITALS MUST FURNISH TO THE BENEFICIARY OR HIS OR HER REPRESENTATIVE AN ITEMIZED STATEMENT OF THE HOSPITAL CHARGES.

None
None


No

1
IC Title Form No. Form Name
INFORMATION COLLECTION REQUIREMENTS AT 42 CFR 411.54(C)(1) ITEMIZED STATEMENT OF HOSPITAL CHARGES HCFA-R-134

  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 1 0 0 0 0
Annual Time Burden (Hours) 1 1 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.
11/12/1991


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