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

Provider-Preventable Conditions under 42 CFR 438.6 and 447.26 and Title 2702 Non-Payment Preprint (Attachment 4.19)

Documents and Forms

Document Name Document Type
Preprint [rev 05-26-11].doc Other-CMS-10364 Preprint

Information Collection (IC) Details

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

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 %

	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

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.