Application for Certification and Recertification as a Federally Qualified Health Center

ICR 199702-0915-002

OMB: 0915-0142

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
0915-0142 199702-0915-002
Historical Active 199312-0915-001
HHS/HSA
Application for Certification and Recertification as a Federally Qualified Health Center
Revision of a currently approved collection   No
Regular
Approved without change 04/18/1997
Retrieve Notice of Action (NOA) 02/21/1997
This information collection is approved for two years subject to the following term of clearance: 1. Upon resubmission, the agency shall undertake to minimize burden while implementing changes to this information collection with respect to potential Medicaid reform and implementation of new section 330 legislation.
  Inventory as of this Action Requested Previously Approved
03/31/1999 03/31/1999 04/30/1997
301 0 200
13,020 0 10,000
2,000 0 0

This application guide is used by organizations applying to the Secretary for certification as Federally Qualified Health Center (FQHC) Look-Alikes for purposes of Medicaid and Medicare cost-based reimbursement. The recertification guide is used by FQHC Look-Alikes annually to apply for recertification.

None
None


No

1
IC Title Form No. Form Name
Application for Certification and Recertification as a Federally Qualified Health Center

  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 301 200 0 0 101 0
Annual Time Burden (Hours) 13,020 10,000 0 0 3,020 0
Annual Cost Burden (Dollars) 2,000 0 0 2,000 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.
02/21/1997


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