Requirements for Requests by Hospitals for an Alternative Cost-to-Charge Ratio and Supp. Regs. in 42CFR412.84(i)(2),412.525(a)(4)(ii), 412.525(a)(4)(iv)(A), 412.529(c)(3)(ii) and 412.529(c)(3)(iv)(A)

Requirements for Requests by Hospitals for an Alternative Cost-to-Charge Ratio and Supp. Regs. in 42CFR412.84(i)(2),412.525(a)(4)(ii), 412.525(a)(4)(iv)(A), 412.529(c)(3)(ii) and 412.529(c)(3)(iv)(A)

OMB: 0938-1020

IC ID: 178499

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Requirements for Requests by Hospitals for an Alternative Cost-to-Charge Ratio and Supp. Regs. in 42CFR412.84(i)(2),412.525(a)(4)(ii), 412.525(a)(4)(iv)(A), 412.529(c)(3)(ii) and 412.529(c)(3)(iv)(A)
 
No New
 
Required to Obtain or Retain Benefits
 
42 CFR 412.84(i)(2) 42 CFR 412.525(a)(4) 42 CFR 412.529(c)(3)

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

Health Health Care Services

 

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Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   75 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 18 0 18 0 0 0
Annual IC Time Burden (Hours) 144 0 144 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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