42 CFR 494.180 (f)(4)(iii)

(CMS-R-52) End State Renal Disease (ESRD) Conditions for Coverage and Supporting Regulations

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Documents and Forms

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no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	42 CFR 494.180 (f)(4)(iii)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 494.180(f)(4)(iii)

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: 7,000	Number of Respondents for Small Entity: 323

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	7,000	536	6,464
Annual IC Time Burden (Hours)	583	44	539
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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