Appointment of Representative and Supporting Regulations in 42 CFR 405.910

ICR 201006-0938-017

OMB: 0938-0950

Federal Form Document

ICR Details
0938-0950 201006-0938-017
Historical Active 200807-0938-001
HHS/CMS
Appointment of Representative and Supporting Regulations in 42 CFR 405.910
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 06/30/2010
Retrieve Notice of Action (NOA) 06/30/2010
  Inventory as of this Action Requested Previously Approved
12/31/2011 12/31/2011 12/31/2011
268,268 0 268,268
67,067 0 67,067
0 0 0

This form will be completed by beneficiaries, providers, and suppliers who wish to appoint representatives to assist them with obtaining initial determinations and filing appeals. The appointment of representative form must be signed by the party making the appointment and the individual agreeing to accept the appointment.

US Code: 18 USC 1869 Name of Law: BIPA
   PL: Pub.L. 106 - 554 521 Name of Law: Medicare, Medicaid, and SCHIP Benefits Improvement Act of 2000 (BIPA)
   PL: Pub.L. 108 - 178 931 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
  
None

0938-AM73 Final or interim final rulemaking 74 FR 65296 12/09/2009

No

  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 268,268 268,268 0 0 0 0
Annual Time Burden (Hours) 67,067 67,067 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
No
Uncollected
No
Uncollected
Bonnie Harkless 4107865666

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
06/16/2010


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