Information Collection

Request for Accelerated Payments Supporting Regs in 42 CFR, section 412.116(f), 412.632(e), 413.64(g), 413.350(d) & 484.245

IC 7921 under ICR 200812-0938-003 · OMB 0938-0269.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0269 can be found here:

Documents and Forms

Document Name Document Type
CMS-9042 Provder Reimbursement Manual 2412 to 2412 5.doc Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Accelerated Payments Supporting Regs in 42 CFR, section 412.116(f), 412.632(e), 413.64(g), 413.350(d) & 484.245	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 412.116(f) 42 CFR 412.632(e) 42 CFR 413.64(g) 42 CFR 413.350(d) 42 CFR 484.245

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-9042 Provder Reimbursement Manual 2412 to 2412 5.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 880	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: 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	880	58	822
Annual IC Time Burden (Hours)	440	29	411
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.