The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376

Forms and Documents

Document Name	Status
Form CMS-379 The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376 Form and Instruction	Modified
CMS-379.Supporting Statement Part A.doc Supporting Statement A	2013-09-06

IC Document Collections

IC ID	Document Title	Status
7924	The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376 Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0270	ICR Reference No: 201309-0938-011
Status: Historical Active	Previous ICR Reference No: 200709-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No: 20494
Title: The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376
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: 02/14/2014
	Date Received in OIRA: 09/12/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2017	36 Months From Approved
Responses	500	0	0
Time Burden (Hours)	1,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This form is used to collect financial information which is needed to evaluate requests from physicians/suppliers to pay indebetedness under an extended repayment schedule, or to compromise a debt less than the full amount.

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Authorizing Statute(s): US Code: 42 USC 1395u Name of Law: null
   Statute at Large: 18 Stat. 1842 Name of Statute: null
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 37542	06/21/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 53766	08/30/2013
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376	CMS-379	Financial Statement of Debtor

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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	500	0	0	0	0	500
Annual Time Burden (Hours)	1,000	0	0	0	0	1,000
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:

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Annual Cost to Federal Government: $23,540

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

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Common Form ICR:  No

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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: 09/12/2013

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