Disclosure of Ownership and Financial Control Interest Statement and Supporting Regulations Contained in 42 CFR 420.200-.206 and 455.100-.106

ICR 199903-0938-006

OMB: 0938-0086

Federal Form Document

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ICR Details
0938-0086 199903-0938-006
Historical Active 199711-0938-001
HHS/CMS
Disclosure of Ownership and Financial Control Interest Statement and Supporting Regulations Contained in 42 CFR 420.200-.206 and 455.100-.106
Extension without change of a currently approved collection   No
Regular
Approved without change 07/01/1999
Retrieve Notice of Action (NOA) 03/15/1999
  Inventory as of this Action Requested Previously Approved
09/30/2002 09/30/2002 07/31/1999
125,000 0 92,000
62,500 0 46,000
0 0 0

This information must be collected by State agencies and HCFA regional offices to determine whether providers/suppliers meet the eligibility requirements for title 18, 19, CLIA, and for grants under titles V and XX. Review of ownership and control is particularly necessary to prohibit ownership and control of individuals excluded under Federal fraud statutes.

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 125,000 92,000 0 0 33,000 0
Annual Time Burden (Hours) 62,500 46,000 0 0 16,500 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.
03/15/1999


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