Provider Reimbursement Manual, Part 1, Chapter 27, Sections 2721, 2722, and 2725; Request for Exception to ESRD Composite Rates and Supporting Regulations Contained in 42 CFR 413.170

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IC Title:	Provider Reimbursement Manual, Part 1, Chapter 27, Sections 2721, 2722, and 2725; Request for Exception to ESRD Composite Rates and Supporting Regulations Contained in 42 CFR 413.170	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-9044				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 275	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	275	-125	400
Annual IC Time Burden (Hours)	13,200	-6,000	19,200
Annual IC Cost Burden (Dollars)	0	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.