Information Collection Requirements Contained in BPD-718: Advance Directive (Medicare and Medicaid)

ICR 199605-0938-009

OMB: 0938-0610

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0610 199605-0938-009
Historical Active 199304-0938-002
HHS/CMS
Information Collection Requirements Contained in BPD-718: Advance Directive (Medicare and Medicaid)
Extension without change of a currently approved collection   No
Regular
Approved without change 07/29/1996
Retrieve Notice of Action (NOA) 05/31/1996
  Inventory as of this Action Requested Previously Approved
07/31/1999 07/31/1999 07/31/1996
38,927 0 32,800
908,250 0 750,000
0 0 0

Certain Medicare and Medicaid organizations are responsible for collecting and documenting, in medical records, whether or not an individual has executed an advance directive. This document indicates the individual's preference if he/she is incapacitated.

None
None


No

1
IC Title Form No. Form Name
Information Collection Requirements Contained in BPD-718: Advance Directive (Medicare and Medicaid) HCFA-R10

  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 38,927 32,800 0 0 6,127 0
Annual Time Burden (Hours) 908,250 750,000 0 0 158,250 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.
05/31/1996


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