Medicare Integrity Program Organizational Conflict of Interest Disclosure Certificate and Supporting Regs at 42 CFR 421.300- 421.316

ICR 200512-0938-004

OMB: 0938-0723

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0723 200512-0938-004
Historical Active 200208-0938-002
HHS/CMS
Medicare Integrity Program Organizational Conflict of Interest Disclosure Certificate and Supporting Regs at 42 CFR 421.300- 421.316
Extension without change of a currently approved collection   No
Regular
Approved without change 02/27/2006
Retrieve Notice of Action (NOA) 12/07/2005
  Inventory as of this Action Requested Previously Approved
02/28/2009 02/28/2009 02/28/2006
11 0 5
2,200 0 1,000
0 0 0

CMS needs this information to assess whether contractors who perform, or who seek to perform, Medicare Integrity Program functions, such as medical review, fraud review or cost audits, have organizational conflicts of interest and whether any conflicts have been resolved. The entities providing the information will be organizations that have been awarded, or seek award of, a Medicare Integrity Program contract.

None
None


No

1
IC Title Form No. Form Name
Medicare Integrity Program Organizational Conflict of Interest Disclosure Certificate and Supporting Regs at 42 CFR 421.300- 421.316 CMS-R-232

  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 11 5 0 0 6 0
Annual Time Burden (Hours) 2,200 1,000 0 0 1,200 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.
12/07/2005


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