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

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0470 can be found here:

Documents and Forms

Document Name Document Type
Form CMS--901A Application for Federal Qualification (901A); Medicare Agreement Application (901D). Regulations in 42 CFR Section 417.143 and 422.6. Form and Instruction
CMS-901D Medicare Agreement Application Health Care Prepayment Pl CMS-901D hcppapp1-2003 01082007.doc Form and Instruction
CMS--901A Application For Federal Qualification CMS-901 fq2000ap901A 01082007.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Application for Federal Qualification (901A); Medicare Agreement Application (901D). Regulations in 42 CFR Section 417.143 and 422.6.	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 417.143 42 CFR 422.6

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 55	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: 50 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	55	0	55
Annual IC Time Burden (Hours)	2,200	-3,758	5,958
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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