Medicare/Medicaid Disclosure of Ownership and Control Interest Statement

Forms and Documents

Document	Type	Status	Availability

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Collection	Type	Status	Form
7836	Medicare/Medicaid Disclosure of Ownership and Control Interest Statement	Form	Migrated

ICR Details

OMB Control No: 0938-0086	ICR Reference No: 199604-0938-003
Status: Historical Active	Previous ICR Reference No: 199311-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare/Medicaid Disclosure of Ownership and Control Interest Statement
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/14/1996
	Date Received in OIRA: 04/30/1996
Terms of Clearance: Consistent with the expiration dates of the National Provider System (OMB # 0938-0684) and the Medicare Carrier Provider/ Supplier Enrollment Application (OMB # 0938-0685), the HCFA-1513 is approved for use through 4/97 under the condition that the next submission for OMB review includes: 1) a side-by-side analysis of the information collected on this form and the content of the Provider/Supplier Enrollment Application, NPS requirements, and the survey/certification OSCAR system; and 2) the schedule for completely phasing out this form, with an update on the development and implementation of new provider enrollment/ application forms. In addition, HCFA must immediately incorporate into the form/instructions the disclosure statements required by the Paperwork Reduction Act of 1995 and its implementing regulations. HCFA must provide OMB a copy of the revised form/instructions for the public record. Finally, OMB notes that this clearance action does not apply to the regula- tions that serve as a basis for the HCFA-1513. HCFA did not explicitly request approval for these regulatory requirements.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/1997	04/30/1997
Responses	60,000	0	0
Time Burden (Hours)	30,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This information must be used by State agencies and HCFA regional offices to determine whether providers meet the eligibility requirements for titles 18 and 19 (Medicare and Medicaid) and for grants under titles V and XX.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicare/Medicaid Disclosure of Ownership and Control Interest Statement	HCFA-1513

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ICR Summary of Burden

	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	60,000	0	0	60,000	0	0
Annual Time Burden (Hours)	30,000	0	0	30,000	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 04/30/1996

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