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

ICR 201405-0938-002

OMB: 0938-0027

Federal Form Document

Forms and Documents
ICR Details
0938-0027 201405-0938-002
Historical Active 201203-0938-006
HHS/CMS
Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form (CMS-1880 and 1882)
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 09/28/2014
Retrieve Notice of Action (NOA) 05/13/2014
  Inventory as of this Action Requested Previously Approved
06/30/2015 06/30/2015 06/30/2015
86 0 86
151 0 151
0 0 0

The Medicare program requires portable X-ray suppliers to be surveyed for health and safety standards. The CMS-1882 is the survey form that records survey results. The CMS-1880 is used by the surveyor to determine if a portable X-ray applicant meets the eligibility requirements.

Statute at Large: 18 Stat. 1861 Name of Statute: null
   Statute at Large: 18 Stat. 1864 Name of Statute: null
   Statute at Large: 18 Stat. 1875 Name of Statute: null
   US Code: 42 USC 486.100 Name of Law: Conditions for Coverage: Portable X-ray Services
  
None

Not associated with rulemaking

  76 FR 80372 12/23/2011
77 FR 14806 03/13/2012
Yes

  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 86 86 0 0 0 0
Annual Time Burden (Hours) 151 151 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$5,935
No
No
No
No
No
Uncollected
Denise King 410 786-1013 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
05/13/2014


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