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Federal forms, ICRs, and supporting documents

Information Collection

Application for Federal Qualification (901A); Medicare Agreement Application (901D). Regulations in 42 CFR Section 417.143 and 422.6.

IC 8097 under ICR 200704-0938-001 · OMB 0938-0470.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Application for Federal Qualification (901A); Medicare Agreement Application (901D). Regulations in 42 CFR Section 417.143 and 422.6.
 
No Modified
 
Voluntary
 
42 CFR 417.143 42 CFR 422.6

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS--901A Application For Federal Qualification CMS-901 fq2000ap901A 01082007.doc Yes Yes Paper Only
Form and Instruction CMS-901D Medicare Agreement Application Health Care Prepayment Plan CMS-901D hcppapp1-2003 01082007.doc Yes Yes Paper Only

Health Health Care Services

 

55 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   50 %

  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 55 0 0 0 0 55
Annual IC Time Burden (Hours) 2,200 0 -3,758 0 0 5,958
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.