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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-370 Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report	Form and Instruction
CMS-370 Health Insurance Benefits Agreement CMS-370 .05.14.24.pdf	Form and Instruction
CMS-370 Health Insurance Benefits Agreement CMS-370 .05.14.24.pdf	Form and Instruction
CMS-377 Ambulatory Surgical Center Request for Initial Certifica CMS377. 05.17.24.pdf	Form and Instruction
CMS-377 Ambulatory Surgical Center Request for Initial Certifica CMS377. 05.17.24.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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 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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,946

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: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,946	379	1,567
Annual IC Time Burden (Hours)	1,559	547	1,012
Annual IC Cost Burden (Dollars)	0	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.