MEDICARE SUPPLIER NUMBER APPLICATION

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
114048	MEDICARE SUPPLIER NUMBER APPLICATION Form	Migrated

ICR Details

OMB Control No: 0938-0594	ICR Reference No: 199109-0938-007
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: MEDICARE SUPPLIER NUMBER APPLICATION
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/24/1991
	Date Received in OIRA: 09/25/1991
Terms of Clearance: Approved for use through 12/92 under the condition that the next form submitted for OMB review: 1) effectively implements the final rul regionalizing claims payment for durable medical equipment; and 2) if appropriate, is revised to reflect consideration of public comment on the proposed DME rule. In addition, the following changes must be made to the form in this clearance package prior to use: 1) The first sentence of the instructions for pg. 1, section 4 B. should be amended to read, "List each individual owner's name and each managing employee's name"; and 2) A new question after 5 A. page 2 should be added: "Has any owner managing employee of this entity ever been associated with a corporation or other business entity that has been sanctioned or is currently under investigation for violations in the Medicare or Medica program? If yes to either question, list below names of such person(s date, business name(s), person's association, and nature of sanction and/or investigation."

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/1992	12/31/1992
Responses	56,667	0	0
Time Burden (Hours)	56,667	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: LEGISLATION REQUIRES ALL SUPPLIERS TO DISCLOSE THE NAMES OF OWNERS AND MANAGING EMPLOYEES. THIS FORM ESTABLISHES A STANDARD FOR THAT DATA COLLECTION. THIS DATA WILL BE USED TO IDENTIFY COMMON OWNERSHIP AND MANAGEMENT AND SANCTIONED INDIVIDUALS IN THE MEDICARE AND MEDICAID PROGRAMS.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
MEDICARE SUPPLIER NUMBER APPLICATION	HCFA-192

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ICR Summary of Burden

	Total Approved	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	56,667	0	0	56,667	0	0
Annual Time Burden (Hours)	56,667	0	0	56,667	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 09/25/1991

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