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)

OMB: 0938-0266

IC ID: 7913

Information Collection (IC) Details

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Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report
 
No Modified
 
Required to Obtain or Retain Benefits
 

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

Health Health Care Services

 

5,947 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 1,833 0 -257 0 0 2,090
Annual IC Time Burden (Hours) 633 0 -14 0 0 647
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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