Appointment of Representative and Supporting Regulations in 42 CFR 405.910

ICR 200503-0938-008

OMB: 0938-0950

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
0938-0950 200503-0938-008
Historical Active
HHS/CMS
Appointment of Representative and Supporting Regulations in 42 CFR 405.910
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 07/08/2005
Retrieve Notice of Action (NOA) 03/28/2005
  Inventory as of this Action Requested Previously Approved
07/31/2008 07/31/2008
5,455,461 0 0
6,819 0 0
0 0 0

This form will be completed by beneficiaries, providers and suppliers who wish to appoint representatives to assist them with obtaining initial determinations. The Appointment of Representative Form must be signed by the party making the appointment and the individual agreeing to accept the appointment.

None
None


No

1
IC Title Form No. Form Name
Appointment of Representative and Supporting Regulations in 42 CFR 405.910 CMS-1696

  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 5,455,461 0 0 5,455,461 0 0
Annual Time Burden (Hours) 6,819 0 0 6,819 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.
03/28/2005


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