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Emergency and Foreign Hospital Services
Emergency and Foreign Hospital Services and Supporting Regulation in 42 CFR Section 424.103 (CMS-1771)
OMB: 0938-0023
IC ID: 7770
OMB.report
HHS/CMS
OMB 0938-0023
ICR 202211-0938-001
IC 7770
( )
Documents and Forms
Document Name
Document Type
Form CMS-1771
Emergency and Foreign Hospital Services
Form
CMS-1771 Emergency and Foreign Hospital Services
FORM_CMS_1771_Clean_Instrument.pdf
Form
CMS-1771 Emergency and Foreign Hospital Services
FORM_CMS_1771_Clean_Instrument.pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Emergency and Foreign Hospital Services
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
Emergency and Foreign Hospital Services
FORM_CMS_1771_Clean_Instrument.pdf
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
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:
Not-for-profit institutions, Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
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
200
0
0
0
0
200
Annual IC Time Burden (Hours)
50
0
0
0
0
50
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
