Advanced Directives (Medicare and Medicard) - BDP-718

Forms and Documents

Document Name	Status
CMS-R-10.REVISED Supporting Statement.CLEAN version.doc Supporting Statement A	2009-05-08

IC Document Collections

IC ID	Document Title	Status
8210	Advanced Directives (Medicare and Medicard) - BDP-718	Removed
189100	CMS-R-10 Form 83 - Part II (Policies and Procedures)	New
189099	CMS-R-10 Form 83 - Part II (Documenting Advanced Directive)	New
189098	CMS-R-10 Form 83 - Part II (Developing Advanced Directive)	New
189097	CMS-R-10 Form 83 - Part II (Annual Update)	New

ICR Details

OMB Control No: 0938-0610	ICR Reference No: 200810-0938-019
Status: Historical Active	Previous ICR Reference No: 200508-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Advanced Directives (Medicare and Medicard) - BDP-718
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/08/2009
	Date Received in OIRA: 10/31/2008
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2012	36 Months From Approved	05/31/2009
Responses	20,378,336	0	33,096
Time Burden (Hours)	1,178,927	0	924,120
Cost Burden (Dollars)	0	0	0

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Abstract: Certain Medicare and Medicaid organizations are responsible for collecting and documenting in a prominent place in medical records whether an individual has executed an advanced directive. This document indicates the individual's preference if he/she is incapacitated.

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Authorizing Statute(s): PL: Pub.L. 101 - 508 4751 Name of Law: Omnibus Reconciliation Act of 1990
   PL: Pub.L. 101 - 508 4206 Name of Law: Omnibus Reconciliation Act of 1990
   PL: Pub.L. 105 - 33 4641 Name of Law: Placement of advance directive in medical record.
   PL: Pub.L. 105 - 33 4002 Name of Law: Transitional rules for current medicare HMO program.
   PL: Pub.L. 105 - 33 4001 Name of Law: Establishment of Medicare+Choice program.
  

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 47957	08/15/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 63478	10/24/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
Advanced Directives (Medicare and Medicard) - BDP-718	CMS-R-10
CMS-R-10 Form 83 - Part II (Documenting Advanced Directive)
CMS-R-10 Form 83 - Part II (Policies and Procedures)
CMS-R-10 Form 83 - Part II (Developing Advanced Directive)
CMS-R-10 Form 83 - Part II (Annual Update)

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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	20,378,336	33,096	0	20,345,240	0	0
Annual Time Burden (Hours)	1,178,927	924,120	0	254,807	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

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)? No

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: 10/31/2008

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