Information Collection

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

IC 8387 under ICR 200512-0938-004 · OMB 0938-0723.

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IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-232				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	11	6	5
Annual IC Time Burden (Hours)	2,200	1,200	1,000
Annual IC Cost Burden (Dollars)	0	0	0

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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.