FEDERAL REIMBURSEMENT OF EMERGENCY HEALTH SERVICES FURNISHED TO UNDOCUMENTED ALIENS (SECTION 1011) PROVIDER ENROLLMENT APPLICATION

Forms and Documents

Document Name	Status
Form CMS-10115 FEDERAL REIMBURSEMENT OF EMERGENCY HEALTH SERVICES FURNISHED TO UNDOCUMENTED ALIENS (SECTION 1011) PROVIDER ENROLLMENT APPLICATION (CMS-10115) Form and Instruction	Modified
Crosswalk_JA 03212013.doc Supplementary Document	2013-07-18
JUSTIFICATION_for_REQUESTING_SOC_SEC_NOS_MED_JA 03212013.doc Supplementary Document	2013-07-18
CMS-10115_PRA_Supporting_Statement_MED [rev 7-18-2013 by OSORA PRA].doc Supporting Statement A	2013-07-18

IC Document Collections

IC ID	Document Title	Status
37924	FEDERAL REIMBURSEMENT OF EMERGENCY HEALTH SERVICES FURNISHED TO UNDOCUMENTED ALIENS (SECTION 1011) PROVIDER ENROLLMENT APPLICATION (CMS-10115) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0929	ICR Reference No: 201307-0938-009
Status: Historical Active	Previous ICR Reference No: 200804-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No: 20082
Title: FEDERAL REIMBURSEMENT OF EMERGENCY HEALTH SERVICES FURNISHED TO UNDOCUMENTED ALIENS (SECTION 1011) PROVIDER ENROLLMENT APPLICATION
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/26/2013
	Date Received in OIRA: 07/19/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2016	36 Months From Approved
Responses	10,000	0	0
Time Burden (Hours)	4,998	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: THIS INFORMATION COLLECTION ALLOWS HOSPITALS, PHYSICIANS AND AMBULANCE PROVIDERS TO ENROLL TO RECEIVE SECTION 1011 PAYMENT, AND ALLOWS ENROLLED PROVIDERS TO MAKE CHANGES TO THEIR CONTACT INFORMATION OR TO DISENROLL FROM THE PROGRAM. THE INFORMATION PROVIDED ON THIS APPLICATION IS USED BY THE CENTERS FOR MEDICARE & MEDICAID SERVICES TO ENSURE PROGRAM PAYMENTS ARE MADE ONLY TO ELIGIBLE PROVIDERS, TO DETERMINE/VERIFY APPLICANT PARTICIPATION IN OTHER FEDERAL PROGRAMS, AND TO IDENTIFY/VERIFY THE EXISTENCE OF ANY PROVIDER SANCTIONS THAT WOULD PRECLUDE THE APPLICANT FROM PARTICIPATING IN A FEDERAL PROGRAM.

---

Authorizing Statute(s): PL: Pub.L. 108 - 179 1011 Name of Law: Federal reimbursement of emergency health services furnished to undocumented aliens
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 25089	04/29/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 41932	07/12/2013
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
FEDERAL REIMBURSEMENT OF EMERGENCY HEALTH SERVICES FURNISHED TO UNDOCUMENTED ALIENS (SECTION 1011) PROVIDER ENROLLMENT APPLICATION (CMS-10115)	CMS-10115	Section 1011 Provider Enrollment Application

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	10,000	0	0	0	0	10,000
Annual Time Burden (Hours)	4,998	0	0	0	0	4,998
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/19/2013

---