Information Collection

Emergency and Foreign Hospital Services

IC 7770 under ICR 202211-0938-001 · OMB 0938-0023.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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

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 %

table that charts list of burden
	Approved	Previously Approved
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

table that charts IC Documents
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.