Information Collection

Application to be Recognized as a Qualified Provider-led Entity (sec. 414.94)

IC 217369 under ICR 201511-0938-007 · OMB 0938-1288.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	Application to be Recognized as a Qualified Provider-led Entity (sec. 414.94)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 414.94(c)(1) and (2)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	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: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	900	900
Annual IC Cost Burden (Dollars)	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.