(CMS-10268) Consolidated Renal Operations in a Web Enabled Network (CROWNWeb) Third-party Submission Authorization Form

Forms and Documents

Document Name	Status
Form CMS-10268 Consolidated Renal Operations in a Web Enabled Network (CROWNWeb) Batch Data Submission Form Form and Instruction	Modified
CMS-10268 Supporting Statement A -3-17-17.doc Supporting Statement A	2017-03-20

IC Document Collections

IC ID	Document Title	Status
186857	Consolidated Renal Operations in a Web Enabled Network (CROWNWeb) Batch Data Submission Form Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1052	ICR Reference No: 201609-0938-017
Status: Historical Active	Previous ICR Reference No: 201308-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No: 20200
Title: (CMS-10268) Consolidated Renal Operations in a Web Enabled Network (CROWNWeb) Third-party Submission Authorization Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/24/2017
	Date Received in OIRA: 09/29/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	36 Months From Approved	03/31/2017
Responses	400	0	400
Time Burden (Hours)	34	0	34
Cost Burden (Dollars)	0	0	0

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Abstract: The sole purpose the CMS-10268 form is to allow Dialysis Facilities to authorize their Corporate Offices to submit data into the CROWNWeb system on their behalf. This five minute effort acutally reduces the Dialysis Facilities burden because they do not have to do monthly data entry on their dialysis patients when they give this authorization to their corporate office. The data is in their corporate system and is electronically entered into CROWNWeb through batch files submissions sent by their corporate office. CMS requires authorization because of the sensitivity of the data. The form is used to document and implement approriate controls on data submission an utilization.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 47807	07/22/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 66031	09/26/2016
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Consolidated Renal Operations in a Web Enabled Network (CROWNWeb) Batch Data Submission Form	CMS-10268	Crownweb Batch Data Submission Authorization form

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ICR Summary 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	400	400	0	0	0	0
Annual Time Burden (Hours)	34	34	0	0	0	0
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:

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Annual Cost to Federal Government: $10,000

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

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Common Form ICR:  No

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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: 09/29/2016

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