INFORMATION COLLECTION REQUIREMENTS CONTAINED IN BPD-718: ADVANCE DIRECTIVES (MEDICARE AND MEDICAID)

ICR 199204-0938-001

OMB: 0938-0610

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0610 199204-0938-001
Historical Active
HHS/CMS
INFORMATION COLLECTION REQUIREMENTS CONTAINED IN BPD-718: ADVANCE DIRECTIVES (MEDICARE AND MEDICAID)
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 06/01/1992
Retrieve Notice of Action (NOA) 04/17/1992
  Inventory as of this Action Requested Previously Approved
05/31/1993 05/31/1993
32,800 0 0
750,000 0 0
0 0 0

CERTAIN MEDICARE AND MEDICAID PROVIDERS AND ORGANIZATIONS ARE RESPONSIBLE FOR COLLECTING AND DOCUMENTING IN MEDICAL RECORDS WHETHER NOT AN INDIVIDUAL HAS EXECUTED AN ADVANCE DIRECTIVE. THIS ADVANCE DIRECTIVE STATES THE INDIVIDUAL'S PREFERENCE FOR HEALTH CARE IN THE EVENT THE INDIVIDUAL IS UNABLE TO DO SO.

None
None


No

1
IC Title Form No. Form Name
INFORMATION COLLECTION REQUIREMENTS CONTAINED IN BPD-718: ADVANCE DIRECTIVES (MEDICARE AND MEDICAID) HCFA-R-10

  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 32,800 0 0 32,800 0 0
Annual Time Burden (Hours) 750,000 0 0 750,000 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.
04/17/1992


© 2024 OMB.report | Privacy Policy