OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Emergency and Foreign Hospital Services and Supporting Regulation in 42 CFR Section 424.103 (CMS-1771)

OMB 0938-0023 · HHS/CMS.

OMB 0938-0023

This form is used in connection with claims for emergency hospital services provided by hospitals that do no have an agreement in effect under Section 1866 of the Social Security Act. 42 CFR 424.103 (b) requires that before a non-participating hospital may be paid for emergency services rendered to a Medicare beneficiary, a statement must be submitted that is

The latest form for Emergency and Foreign Hospital Services and Supporting Regulation in 42 CFR Section 424.103 (CMS-1771) expires 2023-06-30 and is listed under ICR 202002-0938-007.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CMS-1771 Emergency and Foreign Hospital ServicesForm
CMS-1771 Supporting Statement A .docxSupporting Statement A
Emergency and Foreign Hospital Services Form

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202604-0938-017 Reinstatement without change of a previously approved collection 2026-04-22
202211-0938-001 Extension without change of a currently approved collection 2022-11-04 Approved without change
202002-0938-007 Reinstatement without change of a previously approved collection 2020-02-26 Approved without change
201808-0938-006 No material or nonsubstantive change to a currently approved collection 2018-08-03 Approved without change
201602-0938-004 Reinstatement without change of a previously approved collection 2016-02-18 Approved with change
201106-0938-009 Extension without change of a currently approved collection 2011-06-09 Approved with change
200805-0938-008 Extension without change of a currently approved collection 2008-05-19 Approved with change
200504-0938-006 Extension without change of a currently approved collection 2005-04-29 Approved without change
200205-0938-009 Extension without change of a currently approved collection 2002-05-20 Approved without change
199905-0938-010 Extension without change of a currently approved collection 1999-05-27 Approved without change
199606-0938-008 Reinstatement without change of a previously approved collection 1996-06-20 Approved without change
199404-0938-007 Reinstatement with change of a previously approved collection 1994-04-14 Approved without change
199012-0938-001 Extension without change of a currently approved collection 1990-12-10 Approved without change
198905-0938-005 Reinstatement with change of a previously approved collection 1989-05-18 Approved without change
198508-0938-007 Extension without change of a currently approved collection 1985-08-08 Approved without change
198208-0938-002 Revision of a currently approved collection 1982-08-10 Approved without change
197803-0938-017 No material or nonsubstantive change to a currently approved collection 1978-03-29 Approved with change
197709-0938-004 Extension without change of a currently approved collection 1977-09-06 Approved without change
197708-0938-003 No material or nonsubstantive change to a currently approved collection 1977-08-31 Approved with change
197705-0938-001 Extension without change of a currently approved collection 1977-05-24 Approved without change