Medicare Provider Cost Report Reimbursement Questionnaire

ICR 199505-0938-004

OMB: 0938-0301

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
0938-0301 199505-0938-004
Historical Active 199406-0938-001
HHS/CMS
Medicare Provider Cost Report Reimbursement Questionnaire
Revision of a currently approved collection   No
Regular
Approved without change 08/08/1995
Retrieve Notice of Action (NOA) 05/15/1995
  Inventory as of this Action Requested Previously Approved
08/31/1998 08/31/1998 06/30/1997
1 0 0
1,244,745 0 440,120
0 0 0

HCFA-339 must be completed by all providers to ensure proper Medicare reimbursement to providers and to minimize subsequent contact between the provider and its intermediary. It is used to gather information necessary to support financial and statistical entries on the cost report.

None
None


No

1
IC Title Form No. Form Name
Medicare Provider Cost Report Reimbursement Questionnaire HCFA-339

  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 1 0 0 1 0 0
Annual Time Burden (Hours) 1,244,745 440,120 0 804,625 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.
05/15/1995


© 2024 OMB.report | Privacy Policy