Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489

ICR 200104-0938-009

OMB: 0938-0832

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0832 200104-0938-009
Historical Active
HHS/CMS
Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 07/03/2001
Retrieve Notice of Action (NOA) 04/18/2001
  Inventory as of this Action Requested Previously Approved
09/30/2004 09/30/2004
3,000 0 0
150 0 0
0 0 0

Applicants to the Medicare program are required to agree to provide services in accordance with Federal requirements. The HCFA-1561 is essential for HCFA to ensure that applicants are in compliance with the requirements. Applicants will be requied to sign the completed form and provide operational information to HCFA to asure that they continue to meet the requirements after approval.

None
None


No

1
IC Title Form No. Form Name
Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489 HCFA-1561

  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 3,000 0 0 3,000 0 0
Annual Time Burden (Hours) 150 0 0 150 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
04/18/2001


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