Medicare Lifestyle Modification Program Demonstration and Addendum

ICR 200304-0938-002

OMB: 0938-0777

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0777 200304-0938-002
Historical Active 200002-0938-005
HHS/CMS
Medicare Lifestyle Modification Program Demonstration and Addendum
Revision of a currently approved collection   No
Regular
Approved without change 08/25/2003
Retrieve Notice of Action (NOA) 04/04/2003
  Inventory as of this Action Requested Previously Approved
08/31/2006 08/31/2006 08/31/2003
17,996 0 9,000
2,999 0 1,500
0 0 0

This demonstration will focus on Medicare sponsored, lifestyle modification programs designed to reverse, reduce, or ameliorate the progression of cardiovascular disease (CAD) of Medicare beneficiaries at risk for invasive treatment procedures. This demonstration will test the feasibility and cost effectiveness of providing payment for cardiovascular lifestyle modification program services to Medicare beneficiaries.

None
None


No

1
IC Title Form No. Form Name
Medicare Lifestyle Modification Program Demonstration and Addendum CMS-R-289

  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 17,996 9,000 0 8,996 0 0
Annual Time Burden (Hours) 2,999 1,500 0 1,499 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.
04/04/2003


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