Information Collection

Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report

IC 7913 under ICR 201106-0938-018 · OMB 0938-0266.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0266 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-370 Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report	Form
Form CMS-377 Ambulatory Surgical Center (ASC) Request for Initial Certification or Update of Certification Information in the Medicare Program Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report	Form and Instruction
CMS-370 Ambulatory Surgical Center (ASC) Health Insurance Benefi CMS370.pdf	Form
CMS-377 Ambulatory Surgical Center (ASC) Request for Initial Cer CMS377.revised.111610.additional revisions.docx	Form and Instruction

IC Title:

Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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
Form	CMS-370				Yes	No	Paper Only
Form and Instruction	CMS-377				Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,213

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: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,090	-3,000	-33	5,123
Annual IC Time Burden (Hours)	647	-2,000	-140	2,787
Annual IC Cost Burden (Dollars)	0	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.

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