The ambulatory surgical center (ASC)
request for certification form is utilized as an application for
facilities wishing to participate in the Medicare program as an
ASC. This form initiates the process of obtaining a decision as to
whether the conditions of coverage are met. It also promotes data
retrieval from the Online Data Input Edit (ODIE system, a subsystem
of the Online Survey Certification and Report (OSCAR) system by the
Health Care Financing Administration's (HCFA) Regional Offices
(RO)). The ASC report form is an instrument used by the State
survey agency to record data collection in....
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.