Provider Reimbursement Manual, Part 1 - Chapter 27, Sections 2721, 2722 and 2725, Request for Exception to End Stage Renal Disease Composite Rates and Supporting Regulations in 42 CFR..

ICR 200401-0938-008

OMB: 0938-0296

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0296 200401-0938-008
Historical Active 200102-0938-002
HHS/CMS
Provider Reimbursement Manual, Part 1 - Chapter 27, Sections 2721, 2722 and 2725, Request for Exception to End Stage Renal Disease Composite Rates and Supporting Regulations in 42 CFR..
Extension without change of a currently approved collection   No
Regular
Approved without change 04/21/2004
Retrieve Notice of Action (NOA) 01/20/2004
  Inventory as of this Action Requested Previously Approved
04/30/2007 04/30/2007 04/30/2004
125 0 291
6,000 0 14,000
0 0 0

Sections 2721, 2722 and 2725 of the Provider Reimbursement Manual describes the information End Stage Renal Disease facilities must submit in justifying an exception request to their composite rate for outpatient dialysis services.

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 125 291 0 -166 0 0
Annual Time Burden (Hours) 6,000 14,000 0 -8,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes

$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.
01/20/2004


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