Payment Adjustment for Sole Community Hospitals

ICR 199605-0938-010

OMB: 0938-0477

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
8100 Migrated
ICR Details
0938-0477 199605-0938-010
Historical Active 199302-0938-003
HHS/CMS
Payment Adjustment for Sole Community Hospitals
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 07/20/1996
Retrieve Notice of Action (NOA) 05/31/1996
  Inventory as of this Action Requested Previously Approved
07/31/1999 07/31/1999
40 0 0
160 0 0
0 0 0

Hospitals designated "sole community hospitals," that experience a 5 percent decrease in discharges in one cost reporting period, as compared to the previous period, due to unusual circumstances beyond its control, may request an adjustment to its Medicare payment amount.

None
None


No

1
IC Title Form No. Form Name
Payment Adjustment for Sole Community Hospitals HCFA-R-79

  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 40 0 0 40 0 0
Annual Time Burden (Hours) 160 0 0 160 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.
05/31/1996


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