THE LAW REQUIRES THE FILING OF AN
APPLICATION TO ESTABLISH MEDICARE ENTITLEMENT BASED ON END-STAGE
RENAL DISEASE. THE HCFA-43 IS THE APPLICATION FORM USED TO OBTAIN
INFORMATION NEEDED TO DETERMINE MEDICA ELIGIBILITY. IT GUIDES
DISTRICT OFFICE PERSONNEL IN SECURING THE REQUIRED DEVELOPMENT AND
BECOMES A PERMANENT PART OF THE CLAIMS FILE.
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.