Consolidated Renal Operations in a Web Enabled Network (CROWNWeb) Third-party Submission Authorization Form

Forms and Documents

Document Name	Status
Form CMS-10268 Consolidated Renal Operations in a Web Enabled Network (CROWNWeb) Third-party Submission Authorization Form (2nd and 3rd Years) Form and Instruction	New
Form CMS-10268 Consolidated Renal Operations in a Web Enabled Network (CROWNWeb) Third-party Submission Authorization Form (1st Year) Form and Instruction	New
CMS-10268.Supporting Statement CWTPSA-FINAL.doc Supporting Statement A	2008-09-14

IC Document Collections

IC ID	Document Title	Status
186858	Consolidated Renal Operations in a Web Enabled Network (CROWNWeb) Third-party Submission Authorization Form (2nd and 3rd Years) Form and Instruction	New
186857	Consolidated Renal Operations in a Web Enabled Network (CROWNWeb) Third-party Submission Authorization Form (1st Year) Form and Instruction	New

ICR Details

OMB Control No: 0938-1052	ICR Reference No: 200810-0938-008
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Consolidated Renal Operations in a Web Enabled Network (CROWNWeb) Third-party Submission Authorization Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/05/2008
	Date Received in OIRA: 10/08/2008
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2011	36 Months From Approved
Responses	5,100	0	0
Time Burden (Hours)	425	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Consolidated Renal Operations in a Web Enabled Network (CROWNWeb) Third-Party Submission Authorization form is to be completed by "Facility Administrators" (administrators of CMS-certified dialysis facilities) if they intend to authorize a third party (a business with which the facility is associated, or an independent vendor) to submit data to CMS to comply with the recently-revised Conditions for Coverage of dialysis facilities. The CROWNWeb system is the system used as the collection point of data necessary for entitlement of ESRD patients to Medicare benefits and for Federal Government monitoring and assessing of the quality and types of care provided to renal patients. The information collected through the CWTPSA form will allow CMS and its contractors to receive data from authorized parties acting on behalf of CMS-certified dialysis facilities.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 38227	07/03/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 53026	09/12/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Consolidated Renal Operations in a Web Enabled Network (CROWNWeb) Third-party Submission Authorization Form (1st Year)	CMS-10268	CMS-10268.CROWNWeb Batch Data Submission Authorization Form
Consolidated Renal Operations in a Web Enabled Network (CROWNWeb) Third-party Submission Authorization Form (2nd and 3rd Years)	CMS-10268	CMS-10268.CROWNWeb Batch Data Submission Authorization Form

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ICR Summary of Burden

	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	5,100	0	0	5,100	0	0
Annual Time Burden (Hours)	425	0	0	425	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection.

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Annual Cost to Federal Government: $32,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 10/08/2008

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