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Federal forms, ICRs, and supporting documents

Information Collection

Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report

IC 7913 under ICR 202408-0938-021 · OMB 0938-0266.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

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Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report
 
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-370 Health Insurance Benefits Agreement CMS-370 .05.14.24.pdf No   Fillable Fileable
Form and Instruction CMS-377 Ambulatory Surgical Center Request for Initial Certification or Update of Certification Information in the Medicare Program CMS377. 05.17.24.pdf No   Fillable Fileable

Health Health Care Services

 

1,946 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 1,946 0 379 0 1,567 0
Annual IC Time Burden (Hours) 1,559 0 547 0 1,012 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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