Approved for use
through 12/93 under the following conditions: 1) HCFA incorporates
an additional "reason" code on pg. 8 pertaining statutory and
regulatory requirements for physician referrals; and 2) No later
than 1/93, HCFA presents OMB its plans to collect data on an
ongoing basis from laboratories that may have closed due to the
regulatory costs of CLIA. These labs may be identified using a
combin tion of data sources, including Medicare claims files.
Inventory as of this Action
Requested
Previously Approved
12/31/1993
12/31/1993
09/30/1993
320,000
0
320,000
826,667
0
826,667
0
0
0
THESE FORMS (HCFA 114 AND 116) MUST BE
COMPLETED BY ENTITIES PERFORMIN LABORATORY TESTING ON HUMAN
SPECIMENS FOR HEALTH PURPOSES. THE INFORMATION ON THESE FORMS IS
VITAL TO THE CERTIFICATION. WHILE THE HCFA 589 IS COMPLETED ON A
VOLUNTARY BASIS, WE ARE URGING ENTITIES TO COMPLETE THIS FORM SO WE
WILL HAVE NECESSARY BASELINE INFORMATION.
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.