Information Collection

Suppliers that Choose Not to Grandfather - Round 2 (30-Day Notification to Beneficiary)

IC 207248 under ICR 201306-0938-004 · OMB 0938-1079.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1079 can be found here:

Documents and Forms

Document Name Document Type
Sample Letter to Beneficiary from Supplier that Chooses NOT to Grandfather CLEAN 508.pdf Other-Sample Letter

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Suppliers that Choose Not to Grandfather - Round 2 (30-Day Notification to Beneficiary)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.408(j)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Sample Letter			Sample Letter to Beneficiary from Supplier that Chooses NOT to Grandfather CLEAN 508.pdf		No	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 694	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	57,833	57,833
Annual IC Time Burden (Hours)	4,858	4,858
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.