Approved for use through 10/2000 under the condition that the next submission for OMB review discusses and reflects any necessary amendments pursuant to the BBA regulatory negotiation on the Medicare ambulance fee schedule.
Inventory as of this Action
Requested
Previously Approved
10/31/2000
10/31/2000
03/31/1999
9,634,435
0
8,513,300
406,251
0
402,420
14,188,830,000
0
14,188,830,000
This form is completed on an "occasion" basis by beneficiaries and/or ambulance services. Also, it is submitted to a Medicare carrier to request payment for ambulance services.
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.
Request for Medicare Payment, Ambulance -- 42 CFR Section 410.40 and 424.124