Information Collection

Provider-Preventable Conditions under 447.26(c)(1) and Payment for Services Preprint

IC 197984 under ICR 201106-0938-002 · OMB 0938-1136.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Preprint [rev 05-26-11].doc	Other-CMS-10364 Preprint

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 447.26(c)(1)

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-CMS-10364 Preprint			Preprint [rev 05-26-11].doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 55

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	55	55
Annual IC Time Burden (Hours)	385	385
Annual IC Cost Burden (Dollars)	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.