Information Collection

Request for Accelerated Payments Supporting Regs in 42 CFR, section 412.116(f), 412.632(e), 413.64(g), 413.350(d) & 484.245

IC 7921 under ICR 201110-0938-008 · OMB 0938-0269.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-9042 Provder Reimbursement Manual 2412 to 2412 5.doc	Instruction
2011 AP Disclosure Statement.doc 2011 AP Disclosure Statement	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 412.632(e) 42 CFR 413.64(g) 42 CFR 413.350(d) 42 CFR 412.116(f) 42 CFR 484.245

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
Instruction			CMS-9042 Provder Reimbursement Manual 2412 to 2412 5.doc		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 945

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	945	65	880
Annual IC Time Burden (Hours)	473	33	440
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
2011 AP Disclosure Statement	2011 AP Disclosure Statement.doc	10/12/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.