Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form

Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form (CMS-1880 and 1882)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0027 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-1880 Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form Form and Instruction
CMS-1880 Request for Certification as a Supplier of Portable X-ra CMS 1880 Request For Certification.pdf Form and Instruction
CMS-1882 Medicare/Medicaid Portable X-ray Survey Report CMS-1882 Portible X-Ray Survey Report.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 486.100

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1880	Request for Certification as a Supplier of Portable X-ray Services	CMS 1880 Request For Certification.pdf		Yes	No	Fillable Printable
Form and Instruction	CMS-1882	Medicare/Medicaid Portable X-ray Survey Report	CMS-1882 Portible X-Ray Survey Report.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 579	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	86	18	68
Annual IC Time Burden (Hours)	151	32	119
Annual IC Cost Burden (Dollars)	0	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.