OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Electronic Submission of Medicare GME Affiliation Agreements

ICR 201009-0938-005 · OMB 0938-1111 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CMS-10326 Electronic Submission to CMS Form Modified Repair queued
Form CMS-10326 Hardcopy Submission to FI or MAC Form Modified Available
Form CMS-10326 Development of Agreement Form Modified Available
CMS-10326.Supporting Statement Part A (8-13-10).doc Supporting Statement A Uploaded 2010-08-30 Available
IC Document Collections
IC IDCollectionTypeStatusForm
193422 Electronic Submission to CMS Form Modified
193421 Hardcopy Submission to FI or MAC Form Modified
193420 Development of Agreement Form Modified
ICR Details
0938-1111 201009-0938-005
Historical Active 201006-0938-013
HHS/CMS
Electronic Submission of Medicare GME Affiliation Agreements
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 10/29/2010
Retrieve Notice of Action (NOA) 09/20/2010
  Inventory as of this Action Requested Previously Approved
10/31/2013 36 Months From Approved
375 0 0
166 0 0
0 0 0
As discussed in the FY2011 Inpatient Prospective Payment System final rule, we will allow hospitals to electronically submit the copy of the affiliation agreement that is required to be sent to the CMS Central Office. The electronic submission process consists of either an email mailbox or a Web site where hospitals must submit their Medicare GME affiliation agreements to the CMS Central Office to a designated online mailbox. A copy of the Medicare GME affiliation agreement must be received through the electronic system no later than 11:59 p.m. on July 1 of each academic year. The electronic affiliation agreement must be submitted either as a scanned copy or a Printer-Friendly Display (PDF) version of that hard copy agreement; we will not accept an agreement in any electronic format that could be subject to manipulation. The scanned and/or PDF format will enable CMS to ensure that the agreements are signed and dated as required in the regulations at 42 CFR 413.75. Hospitals will have the option to continue to submit a hard copy of its affiliation agreement to the CMS Central Office. In addition, each fiscal intermediary or MAC will continue to have the authority to specify its requirements for submittal of the Medicare GME affiliation agreement by hospitals that are part of the affiliation.
US Code: 42 USC 1395ww Name of Law: Payment to Hospitals for Inpatient Hospital Services
   PL: Pub.L. 105 - 32 4623 Name of Law: Limitation of Number of Residents and Rolling Average FTE Count
  
None
0938-AP80 Final or interim final rulemaking 75 FR 50042 08/16/2010
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 375 0 0 375 0 0
Annual Time Burden (Hours) 166 0 0 166 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Changing Regulations
No
This is a new information collection request.
$0
No
No
No
No
No
Uncollected
William Parham 4107864669
  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.
09/20/2010