Incentive Arrangement Disclosure Form and Supporting Regulations -- 42 CFR 417.479, 417.500, 434.44, 434.70, 1003.100, 1003.101, 1003.103, and 1003.106

ICR 199709-0938-011

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 199709-0938-011
Historical Active 199702-0938-003
HHS/CMS
Incentive Arrangement Disclosure Form and Supporting Regulations -- 42 CFR 417.479, 417.500, 434.44, 434.70, 1003.100, 1003.101, 1003.103, and 1003.106
Revision of a currently approved collection   No
Regular
Approved without change 11/05/1997
Retrieve Notice of Action (NOA) 09/18/1997
  Inventory as of this Action Requested Previously Approved
11/30/2000 11/30/2000 11/30/1997
450 0 450
45,000 0 45,000
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 450 450 0 0 0 0
Annual Time Burden (Hours) 45,000 45,000 0 0 0 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.
09/18/1997


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