MEDICARE/MEDICAID: DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT

ICR 199311-0938-008

OMB: 0938-0086

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0086 199311-0938-008
Historical Active 199108-0938-010
HHS/CMS
MEDICARE/MEDICAID: DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
Extension without change of a currently approved collection   No
Regular
Approved without change 02/20/1994
Retrieve Notice of Action (NOA) 11/22/1993
Approved for use through 8/94 under the condition that HCFA thoroughly addresses OMB's clearance remarks dated 11/27/91.
  Inventory as of this Action Requested Previously Approved
08/31/1994 08/31/1994 11/30/1993
40,000 0 40,000
20,000 0 20,000
0 0 0

HEALTH CARE FACILITIES, ELIGIBILITY DETERMINATION, MEDICARE, MEDICAID THIS INFORMATION WILL BE USED BY THE STATE AGENCY AND HCFA REGIONAL OFFICES TO MAKE ELIGIBILITY DETERMINATIONS FOR PROVIDER PARTICIPATION

None
None


No

1
IC Title Form No. Form Name
MEDICARE/MEDICAID: DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT HCFA-1513

  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 40,000 40,000 0 0 0 0
Annual Time Burden (Hours) 20,000 20,000 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.
11/22/1993


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