Information Collection

Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report and Supporting Regulations in 42 CFR 416.41, 416.43, 416.47, and...

IC 7913 under ICR 200802-0938-001 · OMB 0938-0266.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0266 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-370 Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report and Supporting Regulations in 42 CFR 416.41, 416.43, 416.47, and... Form and Instruction
CMS-370 Health Insurance Benefits Agreement CMS370.pdf Form and Instruction
CMS-377 Ambulatory Surgical Center Request for Certification in cms377.pdf Form and Instruction
CMS-378 Ambulatory Surgical Center Survey Report Form cms378.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report and Supporting Regulations in 42 CFR 416.41, 416.43, 416.47, and...	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-370	Health Insurance Benefits Agreement	CMS370.pdf	No	No	Paper Only
Form and Instruction	CMS-377	Ambulatory Surgical Center Request for Certification in the Medicare Program	cms377.pdf	No	No	Paper Only
Form and Instruction	CMS-378	Ambulatory Surgical Center Survey Report Form	cms378.pdf	No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,123	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,123	811	4,312
Annual IC Time Burden (Hours)	2,787	406	2,381
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.