Medicare Participating Physician or Supplier Agreement

ICR 200507-0938-009

OMB: 0938-0373

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
0938-0373 200507-0938-009
Historical Active 200207-0938-012
HHS/CMS
Medicare Participating Physician or Supplier Agreement
Extension without change of a currently approved collection   No
Regular
Approved without change 09/12/2005
Retrieve Notice of Action (NOA) 07/22/2005
This information collection is approved for one year with the following terms of clearance. Prior to resubmission, the agency will provide a web-based form that can be filled out via the Internet.
  Inventory as of this Action Requested Previously Approved
10/31/2006 10/31/2006 10/31/2005
6,000 0 6,250
1,500 0 1,563
0 0 0

CMS-460 is completed by nonparticipating physicians and suppliers if they choose to participate in Medicare Part B. The physician or supplier agrees to take assignment on all Medicare claims. Taking assignment means accepting the Medicare allowed amount as payment in full for the services furnished and charging the beneficiary no more than the deductible and coinsurance for the covered service. By signing the agreement, the physician or supplier receives a number of program benefits not available to nonparticipating suppliers. The information is needed to know to whom to....

None
None


No

1
IC Title Form No. Form Name
Medicare Participating Physician or Supplier Agreement CMS-460

  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 6,000 6,250 0 0 -250 0
Annual Time Burden (Hours) 1,500 1,563 0 0 -63 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
07/22/2005


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