Information Collection

Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report and Supporting Regulations in 42 CFR 416.41, 416.43, 416.47, and...

IC 7913 under ICR 200412-0938-001 · OMB 0938-0266.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0266 can be found here:

Documents and Forms

Documents and forms in this information collection
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Information Collection (IC) Details

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IC Title:

Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report and Supporting Regulations in 42 CFR 416.41, 416.43, 416.47, and...

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	CMS-377	No	No
Form	CMS-370	No	No
Form	CMS-R-54	No	No
Form	CMS-378	No	No

Federal Enterprise Architecture Business Reference Module

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,312

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4,312	637	3,675
Annual IC Time Burden (Hours)	2,381	506	1,875
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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