Information Collection

Request For Approval As A Supplier Of Esrd Services In The Medicare Program

IC 112121 under ICR 199310-0935-001 · OMB 0935-0055.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

REQUEST FOR APPROVAL AS A SUPPLIER OF ESRD SERVICES IN THE MEDICARE PROGRAM

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-3402				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,101

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,101	1,101
Annual IC Time Burden (Hours)	184	184
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.