Election to be paid 100% of PPS rates rather than 5-year phase-in and Notification of FIs and CMS of co-located Medicare providers and Supporting Regulations in 42 CFR, Sections 412.22 and 412.533

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IC Title:	Election to be paid 100% of PPS rates rather than 5-year phase-in and Notification of FIs and CMS of co-located Medicare providers and Supporting Regulations in 42 CFR, Sections 412.22 and 412.533	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 412.22(e)(6) 42 CFR 412.22(h)(5) 42 CFR 412.533(b)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 194	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	194	194
Annual IC Time Burden (Hours)	49	49
Annual IC Cost Burden (Dollars)	0	0

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