Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form

(CMS-1880) Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form

Documents and Forms

Document Name Document Type
Form CMS-1880 Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form Form and Instruction
CMS-1880 Request for Certification as Supplier of Portable Xray E Form CMS-1880.pdf Form and Instruction
Change Crosswalk for CMS-1880. 03.01.21.docx Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 486.100

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1880	Request for Certification as Supplier of Portable Xray Equipment	Form CMS-1880.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 505	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	104	18	86
Annual IC Time Burden (Hours)	26	4	22
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Change Crosswalk for CMS-1880. 03.01.21.docx	08/13/2021

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