Procedure Nominations

Ambulatory Surgical Center (ASC) Covered Procedure List (CPL) Pre-Proposed Rule Recommendation Request (CMS-10809)

Documents and Forms

Document Name Document Type
Form CMS-10809 Procedure Nominations Form and Instruction
CMS-10809 ASC CPL Pre-Proposed Rule Recommendation Request ASC CPL Pre-Proposed Rule Recommendation Request.pdf Form and Instruction
CMS-10809 ASC CPL Pre-Proposed Rule Recommendation Request ASC CPL Pre-Proposed Rule Recommendation Request.pdf Form and Instruction
CMS-10809 MEARIS Screenshots MEARIS Screenshots.pdf Form and Instruction
CMS-10809 MEARIS Screenshots MEARIS Screenshots.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Procedure Nominations	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 416 Sec 2 42 CFR 416 Sec 166

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10809	ASC CPL Pre-Proposed Rule Recommendation Request	ASC CPL Pre-Proposed Rule Recommendation Request.pdf		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10809	MEARIS Screenshots	MEARIS Screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	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.