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Signature Attestation
Fee-for-Service Recovery Audit Prepayment Review Demonstration and Prior Authorization Demonstration
OMB: 0938-1169
IC ID: 202524
OMB.report
HHS/CMS
OMB 0938-1169
ICR 201406-0938-003
IC 202524
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1169 can be found here:
2018-02-07 - Reinstatement without change of a previously approved collection
2014-12-30 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Signature Attestation
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 421.200, 210, 304, 400
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
4,750
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
4,750
0
0
0
0
4,750
Annual IC Time Burden (Hours)
1,188
0
-4,372
0
0
5,560
Annual IC Cost Burden (Dollars)
0
0
0
0
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.