The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376

ICR 200709-0938-010

OMB: 0938-0270

Federal Form Document

IC Document Collections
ICR Details
0938-0270 200709-0938-010
Historical Active 200407-0938-002
HHS/CMS
The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376
Extension without change of a currently approved collection   No
Regular
Approved without change 01/17/2008
Retrieve Notice of Action (NOA) 09/27/2007
  Inventory as of this Action Requested Previously Approved
01/31/2011 36 Months From Approved 01/31/2008
500 0 500
1,000 0 1,000
0 0 0

This form is used to collect financial information which is needed to evaluate requests from physicians/suppliers to pay indebetedness under an extended repayment schedule, or to compromise a debt less than the full amount.

Statute at Large: 18 Stat. 1842 Name of Statute: null
   US Code: 42 USC 1395u Name of Law: null
  
None

Not associated with rulemaking

  72 FR 38601 07/13/2007
72 FR 54042 09/21/2007
No

1
IC Title Form No. Form Name
The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376 CMS-379 Financial Statement of Debtor

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 500 500 0 0 0 0
Annual Time Burden (Hours) 1,000 1,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$20,385
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Bonnie Harkless 4107865666

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
09/27/2007


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