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⚠️ Notice: This information collection may be referencing outdated material.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 Portable X-ray Survey Report CMS-1882_Rev_2014.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	Portable X-ray Survey Report	CMS-1882_Rev_2014.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	Previously Approved
Annual Number of Responses for this IC	86	86
Annual IC Time Burden (Hours)	151	151
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.