The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376 (CMS-379 )

ICR 202408-0938-035

OMB: 0938-0270

Federal Form Document

ICR Details
0938-0270 202408-0938-035
Received in OIRA 202003-0938-017
HHS/CMS OFM
The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376 (CMS-379 )
Reinstatement without change of a previously approved collection   No
Regular 11/05/2024
  Requested Previously Approved
36 Months From Approved
500 0
1,000 0
0 0

This form is used to collect financial information which is needed to evaluate requests from physicians/suppliers to pay indebetedness under an extended repayment schedule, or to compromise a debt less than the full amount.

Statute at Large: 18 Stat. 1842
   US Code: 42 USC 1395u
  
None

Not associated with rulemaking

  89 FR 67442 08/20/2024
89 FR 86806 10/31/2024
No

1
IC Title Form No. Form Name
The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376 CMS-379 Financial Statement Debtor

  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 500 0 0 0 0 500
Annual Time Burden (Hours) 1,000 0 0 0 0 1,000
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$26,410
No
    No
    No
No
No
No
No
Malcolm Wilson 667 414-0087 [email protected]

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
11/05/2024


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