Incentive Arrangement Disclosure Form and Supporting Regulations -- 42 CFR 417.479, 417.500, 434.44, 434.67, 434.70, 1003.100, 1003.101, 1003.103

ICR 199702-0938-003

OMB: 0938-0700

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0700 199702-0938-003
Historical Active
HHS/CMS
Incentive Arrangement Disclosure Form and Supporting Regulations -- 42 CFR 417.479, 417.500, 434.44, 434.67, 434.70, 1003.100, 1003.101, 1003.103
New collection (Request for a new OMB Control Number)   No
Emergency 02/21/1997
Approved without change 04/10/1997
Retrieve Notice of Action (NOA) 02/19/1997
Approved for use through 10/97 under the conditions that: 1) HCFA will accept copies of state-mandated submissions if such reports include all of the necessary elements of information as required by HCFA and the statute; and 2) MCOs may maintain records supporting the summary reports in any format, as long as it is possible to understand and derive from these detailed records all summary statistics reported to HCFA.
  Inventory as of this Action Requested Previously Approved
11/30/1997 11/30/1997
450 0 0
45,000 0 0
0 0 0

Data collection will be used to demonstrate and monitor compliance with the statute governing physician incentives under Medicare and Medicaid managed care.

None
None


No

  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 450 0 0 450 0 0
Annual Time Burden (Hours) 45,000 0 0 45,000 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.
02/19/1997


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