Attending Physicians Statement and Documentation of Medicare Emergency and Supporting Regulations in 42 CFR Section 424.103 (CMS-1771)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0023 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-1771 Attending Physicians Statement and Documentation of Medicare Emergency and Supporting Regulations in 42 CFR Section 424.103 (CMS-1771) Form
CMS-1771 Attending Physician's Statement and Documentation of Med FORM_CMS_1771_Clean_Instrument.pdf Form

Information Collection (IC) Details

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IC Title:	Attending Physicians Statement and Documentation of Medicare Emergency and Supporting Regulations in 42 CFR Section 424.103 (CMS-1771)	Agency IC Tracking Number:	CM-FFS

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 424.103

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-1771	Attending Physician's Statement and Documentation of Medicare Emergency	FORM_CMS_1771_Clean_Instrument.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	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: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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