Attending Physicians Statement and Documentation of Medicare Emergency and Supporting Regulations in 42 CFR Section 424.103

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-1771 Attending Physician's Statement and Documentation of Medicare Emergency	Form	Unchanged	Available
CMS-1771.Supporting Statement Part A (11-18-16) CLEAN.docx	Supporting Statement A	Uploaded 2016-11-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7770	Attending Physicians Statement and Documentation of Medicare Emergency and Supporting Regulations in 42 CFR Section 424.103	Form	Unchanged	Attending Physician's Statement and Documentation of Medicare Emergency

ICR Details

OMB Control No: 0938-0023	ICR Reference No: 201602-0938-004
Status: Historical Active	Previous ICR Reference No: 201106-0938-009
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-1771
Title: Attending Physicians Statement and Documentation of Medicare Emergency and Supporting Regulations in 42 CFR Section 424.103
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/21/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/18/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2019	36 Months From Approved
Responses	200	0	0
Time Burden (Hours)	50	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Form CMS-1771 requires the attending physician to attest that the hospitalization was required under the regulatory emergency definition (42 CFR 424.101) and give clinical documentation to support the claim. This allows a nonparticipating hospital to be paid for emergency services rendered to a Medicare beneficiary.

---

Authorizing Statute(s): Statute at Large: 18 Stat. 1814
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 56999	09/21/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 6277	02/05/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Attending Physicians Statement and Documentation of Medicare Emergency and Supporting Regulations in 42 CFR Section 424.103	CMS-1771	Attending Physician's Statement and Documentation of Medicare Emergency

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	200	0	0	0	0	200
Annual Time Burden (Hours)	50	0	0	0	0	50
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $993

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/18/2016

---