Information Collection

The Application for Federal Qualification (CMS 901A) Regulations in 42 CFR Section 417.140 and the Medicare Health Care Prepayment Plan Application (CMS 901D) in 42 CFR 417.800.

IC 8097 under ICR 201008-0938-002 · OMB 0938-0470.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
2012 HCPP.zip	Other-Medicare Health Care Prepaymen
2011 FQA.zip	Other-Application for Federal Qualif

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

The Application for Federal Qualification (CMS 901A) Regulations in 42 CFR Section 417.140 and the Medicare Health Care Prepayment Plan Application (CMS 901D) in 42 CFR 417.800.

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 417.140 42 CFR 417.800

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Medicare Health Care Prepayment Plan Application Package (CMS-901D)			2012 HCPP.zip		Yes	Yes	Fillable Printable
Other-Application for Federal Qualification Package (CMS-901A)			2011 FQA.zip		Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 20 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20	-35	55
Annual IC Time Burden (Hours)	800	-1,400	2,200
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.