Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report

Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report (CMS-377; CMS-370)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0266 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-370 Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report Form and Instruction
CMS-370 Health Insurance Benefits Agreement CMS370.pdf Form and Instruction
CMS-377 Ambulatory Surgical Center Request for Initial Certifica CMS377.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-370	Health Insurance Benefits Agreement	CMS370.pdf		No		Fillable Fileable
Form and Instruction	CMS-377	Ambulatory Surgical Center Request for Initial Certification or Update of Certification Information in the Medicare Program	CMS377.pdf		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,947	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 Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,833	-257	2,090
Annual IC Time Burden (Hours)	633	-14	647
Annual IC Cost Burden (Dollars)	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.