Medicare + Choice Provider-Sponsored Organization Waiver Request Form -- 42 CFR 422.370 through 422.378

ICR 199807-0938-008

OMB: 0938-0722

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0722 199807-0938-008
Historical Active 199803-0938-005
HHS/CMS
Medicare + Choice Provider-Sponsored Organization Waiver Request Form -- 42 CFR 422.370 through 422.378
Revision of a currently approved collection   No
Regular
Approved without change 09/18/1998
Retrieve Notice of Action (NOA) 07/20/1998
  Inventory as of this Action Requested Previously Approved
09/30/2001 09/30/2001 10/31/1998
30 0 30
300 0 300
0 0 0

The PSO waiver request form is for use by provider-sponsored organizations that wish to enter into a Medicare + Choice contract with the Health Care Financing Administration to provide prepaid health care services to eligible Medicare beneficiaries without a State risk-bearing entity license. HCFA will use the information requested by this form to determine whether the applicant is eligible for a waiver of the State licensure requirement for Medicare + Chioice organizations as allowed under section 1855(a)(2) of the Social Security Act and implementing regulations at 42 CFR 422.370.

None
None


No

1
IC Title Form No. Form Name
Medicare + Choice Provider-Sponsored Organization Waiver Request Form -- 42 CFR 422.370 through 422.378 HCFA-R-231

  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 30 30 0 0 0 0
Annual Time Burden (Hours) 300 300 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.
07/20/1998


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