MEDICARE -- REQUEST TO ESTABLISH ELIGIBILITY IN THE MEDICARE AND/OR MEDICAID PROGRAM TO PROVIDE OUTPATIENT PHYSICAL THERAPY AND/OR SPEECH PATHOLOGY SERVICES -- OUTPATIENT ....

ICR 199205-0938-003

OMB: 0938-0065

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0065 199205-0938-003
Historical Active 199111-0938-001
HHS/CMS
MEDICARE -- REQUEST TO ESTABLISH ELIGIBILITY IN THE MEDICARE AND/OR MEDICAID PROGRAM TO PROVIDE OUTPATIENT PHYSICAL THERAPY AND/OR SPEECH PATHOLOGY SERVICES -- OUTPATIENT ....
Revision of a currently approved collection   No
Regular
Approved without change 08/20/1992
Retrieve Notice of Action (NOA) 05/28/1992
  Inventory as of this Action Requested Previously Approved
08/31/1995 08/31/1995 01/31/1995
650 0 650
1,138 0 1,138
0 0 0

HCFA-1856, REQUEST TO ESTABLISH ELIGIBILITY IN THE MEDICARE AND/OR MEDICAID PROGRAM TO PROVIDE OUTPATIENT PHYSICAL THERAPY AND/OR SPEECH PATHOLOGY SERVICES, IS A FACILITY IDENTIFICATION AND SCREENING FORM US TO INITIATE THE CERTIFICATION PROCESS AND TO DETERMINE IF THE PROVIDER HAS SUFFICIENT PERSONNEL TO PARTICIPATE IN THE MEDICARE/MEDICAID

None
None


No

  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 650 650 0 0 0 0
Annual Time Burden (Hours) 1,138 1,138 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.
05/28/1992


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