Federal Funding of Emergency Health Services (Section 1011) Provider Payment Determination (CMS-10130A)

Federal Funding of Emergency Health Services (Section 1011); Provider Payment Determination and On-Call Cost Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0952 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10130A Federal Funding of Emergency Health Services (Section 1011) Provider Payment Determination (CMS-10130A) Form and Instruction
CMS-10130A Section 1011 Provider Payment Determination CMS10130A.PDF Form and Instruction

Information Collection (IC) Details

IC Title:	Federal Funding of Emergency Health Services (Section 1011) Provider Payment Determination (CMS-10130A)	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10130A	Section 1011 Provider Payment Determination	CMS10130A.PDF		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12,000	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: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	300,000	-7,212,000	7,512,000
Annual IC Time Burden (Hours)	74,970	-559,030	634,000
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.