MEDICARE CONTRACT APPLICATION FOR FEDERALLY QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS, MEDICARE CONTRACT APPLICATION: COMPETITIVE MEDICAL PLAN, QUALIFICATION APPLICATION

ICR 199407-0938-006

OMB: 0938-0470

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0470 199407-0938-006
Historical Active 199310-0938-019
HHS/CMS
MEDICARE CONTRACT APPLICATION FOR FEDERALLY QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS, MEDICARE CONTRACT APPLICATION: COMPETITIVE MEDICAL PLAN, QUALIFICATION APPLICATION
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 10/12/1994
Retrieve Notice of Action (NOA) 07/14/1994
  Inventory as of this Action Requested Previously Approved
07/31/1997 07/31/1997
65 0 0
6,500 0 0
0 0 0

THE SUBJECT FORMS WILL BE USED AS INSTRUMENTS THROUGH WHICH ENTITIES WILL APPLY AND FURNISH INFORMATION TO OPHCOO IN ORDER TO OBTAIN FEDERA QUALIFICATION STATUS, COMP ELIGIBILITY, MEDICARE CONTRACT STATUS (RISK-BASED OR COST-BASED), OR SERVICE AREA EXPANSION.

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 65 0 0 65 0 0
Annual Time Burden (Hours) 6,500 0 0 6,500 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
07/14/1994


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