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End Stage Renal Disease Application and Survey and Certification Report Form and Supporting Regulations 42 CFR 488.60

IC 8003 under ICR 202205-0938-004 · OMB 0938-0360.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
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End Stage Renal Disease Application and Survey and Certification Report Form and Supporting Regulations 42 CFR 488.60
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-3427 ESRD Application and Survey and Certification Report CMS 3427 ESRD Application-Notification and Survey- Certification Report -.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

2,601 0
   
Private Sector Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,601 0 128 0 2,473 0
Annual IC Time Burden (Hours) 866 0 42 0 824 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk CMS 3427 Crosswalk of Changes (508) 110119.docx 02/11/2020
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.