Information Collection

Provider-Preventable Conditions (GenIC #32) and DRA 6062 (GenIC #33)

IC 212383 under ICR 201111-0938-009 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 (#32) Provider-Preventable Conditions (GenIC #32) and DRA 6062 (GenIC #33)	Form
Instructions - Provider-Preventable Conditions (#32) [rev 7-17-2014 at 2_00 pm by OSORA PRA].docx	Instruction
CMS-10398 (#32) Preprint - Provider-Preventable Conditions for Non-Payme Pre-Print - Provider-Preventable Conditions (#32) [rev 7-17-2014 at 2_00 pm by OSORA PRA].docx	Form
CMS-10398 (#33) DRA 6062 (Preprint Attachments 2.2-A and 2.6-A) Preprint - DRA 6062 (#33) [rev 7-17-2014 by OSORA PRA].docx	Form
Supporting Statement - Provider-Preventable Conditions (#32) [rev 7-17-2014 at 1_30 pm by OSORA PRA].docx Supporting Statement - Provider-Preventable Conditions (GenIC #32)	IC Document
DRA 6062 Supporting Statement [rev 7-18-2014 by OSORA PRA].docx Supporting Statement - DRA 6062 (GenIC #33)	IC Document

IC Title:

Provider-Preventable Conditions (GenIC #32) and DRA 6062 (GenIC #33)

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 (#32)	Preprint - Provider-Preventable Conditions for Non-Payment under Section 4.19	Pre-Print - Provider-Preventable Conditions (#32) [rev 7-17-2014 at 2_00 pm by OSORA PRA].docx	Yes	Yes	Fillable Printable
Instruction			Instructions - Provider-Preventable Conditions (#32) [rev 7-17-2014 at 2_00 pm by OSORA PRA].docx	No		Printable Only
Form	CMS-10398 (#33)	DRA 6062 (Preprint Attachments 2.2-A and 2.6-A)	Preprint - DRA 6062 (#33) [rev 7-17-2014 by OSORA PRA].docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 42

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	42	42
Annual IC Time Burden (Hours)	3,278	3,278
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement - Provider-Preventable Conditions (GenIC #32)	Supporting Statement - Provider-Preventable Conditions (#32) [rev 7-17-2014 at 1_30 pm by OSORA PRA].docx	07/18/2014
Supporting Statement - DRA 6062 (GenIC #33)	DRA 6062 Supporting Statement [rev 7-18-2014 by OSORA PRA].docx	07/18/2014

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