COVID–19 Provider Relief Programs Application and Attestation Portal, and Claims Reimbursement Submission Activities

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 4 UIP_Portal_Screenshots.docx	Form	New	Available
Form 4 Uninsured Provider (UIP) Application	Form	New	Repair queued
Form 3 CAF Application Screenshots.pdf	Form	New	Available
Form 3 Coverage Assistance Fund (CAF) Application	Form	New	Repair queued
Form 2 PRF and ARP-R Attestation and Application Screenshots.pptx	Form	New	Available
Form 2 PRF and ARP-R Application Portal	Form	New	Repair queued
Form 1 PRF and ARP-R Attestation and Application Screenshots.pptx	Form	New	Available
Form 1 Provider Relief Fund (PRF) and American Rescue Plan Act Rural (ARP-R) Attestation Portal	Form	New	Repair queued
Supporting Statement A.docx	Supporting Statement A	Uploaded 2022-01-20	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
251212	Uninsured Provider (UIP) Application	Form	New	UIP_Portal_Screenshots.docx
251212	Uninsured Provider (UIP) Application	Form	New
251211	Coverage Assistance Fund (CAF) Application	Form	New	CAF Application Screenshots.pdf
251211	Coverage Assistance Fund (CAF) Application	Form	New
251210	PRF and ARP-R Application Portal	Form	New	PRF and ARP-R Attestation and Application Screenshots.pptx
251210	PRF and ARP-R Application Portal	Form	New
251209	Provider Relief Fund (PRF) and American Rescue Plan Act Rural (ARP-R) Attestation Portal	Form	New	PRF and ARP-R Attestation and Application Screenshots.pptx
251209	Provider Relief Fund (PRF) and American Rescue Plan Act Rural (ARP-R) Attestation Portal	Form	New

ICR Details

OMB Control No: 0906-0069	ICR Reference No: 202201-0906-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: COVID–19 Provider Relief Programs Application and Attestation Portal, and Claims Reimbursement Submission Activities
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/22/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/21/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2025	36 Months From Approved
Responses	815,000	0	0
Time Burden (Hours)	530,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Providers who apply for Provider Relief Programs (i.e., Provider Relief Fund (PRF), American Rescue Plan Act, Rural (ARPA-R), Coverage Assistance Fund (CAF), and Uninsured Provider (UIP) payments) must apply for direct provider payments or claims reimbursement and attest to a set of terms and conditions to enable HRSA’s appropriate disbursement and oversight of recipients’ use of funds, which total up to almost $200 billion. Information collected will allow for (1) assessing if recipients have met statutory and programmatic requirements, (2) conducting audits, (3) gathering data required to calculate, disburse, and report on PRF, ARPA-R, CAF, and UIP payments, and (4) program evaluation. HRSA staff will also use information collected to identify and report on trends of the COVID-19 pandemic on healthcare providers and uninsured or underinsured patients throughout the United States.

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Authorizing Statute(s): PL: Pub.L. 116 - 136 0 Name of Law: Coronavirus Aid, Relief and Economic Security Act
   PL: Pub.L. 116 - 139 0 Name of Law: Paycheck Protection Program and Health Care Enhancement Act
   PL: Pub.L. 116 - 260 0 Name of Law: (Division M) Coronavirus Response and Relief Supplemental Appropriations Act
   PL: Pub.L. 116 - 127 0 Name of Law: Families First Coronavirus Response Act
   PL: Pub.L. 117 - 2 0 Name of Law: American Rescue Plan Act of 2021
  

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:
	86 FR 47119	08/23/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 69657	12/08/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Coverage Assistance Fund (CAF) Application	3	CAF Application Screenshots.pdf
PRF and ARP-R Application Portal	2	PRF and ARP-R Attestation and Application Screenshots.pptx
Provider Relief Fund (PRF) and American Rescue Plan Act Rural (ARP-R) Attestation Portal	1	PRF and ARP-R Attestation and Application Screenshots.pptx
Uninsured Provider (UIP) Application	4	UIP_Portal_Screenshots.docx

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ICR Summary of Burden

table that charts list 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	815,000	0	0	815,000	0	0
Annual Time Burden (Hours)	530,000	0	0	530,000	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new ICR, burden increases from zero (0). Contractor is assessing the ability to add ICR information and public burden statement to portal introduction screen.

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Annual Cost to Federal Government: $150,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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? Yes

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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: 01/21/2022

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