MPAF Data and Supporting Regulations in 42 CFR Sections 413.337, 413.343, 424.32 and 483.20

Documents and Forms

Document Name Document Type
Form CMS-R-250 MPAF Data and Supporting Regulations in 42 CFR Sections 413.337, 413.343, 424.32 and 483.20 Form
MDS20MDSAllForms 32.pdf Other-Form page 2
MDS20MDSAllForms 33.pdf Other-Form page 3
MDS20MDSAllForms 34.pdf Other-Form page 4
MDS20MDSAllForms 35.pdf Other-Form page 5
CMS-R-250 MDS Medicare PPS Assessment Form MDS20MDSAllForms 31.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	MPAF Data and Supporting Regulations in 42 CFR Sections 413.337, 413.343, 424.32 and 483.20	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 413.337 42 CFR 413.343 42 CFR 424.32 42 CFR 483.20

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-250	MDS Medicare PPS Assessment Form	MDS20MDSAllForms 31.pdf	Yes	Yes	Paper Only
Other-Form page 2			MDS20MDSAllForms 32.pdf	Yes	Yes	Paper Only
Other-Form page 3			MDS20MDSAllForms 33.pdf	Yes	Yes	Paper Only
Other-Form page 4			MDS20MDSAllForms 34.pdf	Yes	Yes	Paper Only
Other-Form page 5			MDS20MDSAllForms 35.pdf	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 734	Number of Respondents for Small Entity: 353

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	187,170	187,170
Annual IC Time Burden (Hours)	132,011	132,011
Annual IC Cost Burden (Dollars)	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.