The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376

Forms and Documents

Document Name	Status
Form CMS-379 The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376 Form and Instruction	Modified
CMS-379 Supporting Statement Part AVJ508.docx Supporting Statement A	2016-12-22

IC Document Collections

IC ID	Document Title	Status
7924	The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376 Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0270	ICR Reference No: 201612-0938-002
Status: Historical Active	Previous ICR Reference No: 201309-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-379
Title: The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/13/2017
	Date Received in OIRA: 12/23/2016
Terms of Clearance: The expiration date for the approved form is now March 2020. CMS requested a July 2020 expiration, but that is beyond the time granted by this approval.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	36 Months From Approved	03/31/2017
Responses	500	0	500
Time Burden (Hours)	1,000	0	1,000
Cost Burden (Dollars)	0	0	0

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Abstract: This form is used to collect financial information which is needed to evaluate requests from physicians/suppliers to pay indebetedness under an extended repayment schedule, or to compromise a debt less than the full amount.

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Authorizing Statute(s): Statute at Large: 18 Stat. 1842 Name of Statute: null
   US Code: 42 USC 1395u Name of Law: null
  

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 44610	07/08/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 75409	10/31/2016
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
The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376	CMS-379	Financial Statement of Debtor

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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	500	500	0	0	0	0
Annual Time Burden (Hours)	1,000	1,000	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: $24,285

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: 12/23/2016

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