End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration

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
7802	End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration Form	Migrated

ICR Details

OMB Control No: 0938-0046	ICR Reference No: 199607-0938-001
Status: Historical Active	Previous ICR Reference No: 199410-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/23/1996
	Date Received in OIRA: 07/02/1996
Terms of Clearance: OMB approves this information collection through August 1997 cont ingent upon compliance with the following conditions: 1.) HCFA removes item 16 from the paperwork and places it on HCFA-2746 (ESRD Death Notification). OMB believes that benefit eligibility should be decoupled from the collection of research data. HCFA has already stated that the co-morbid data is used to further epidemiological research efforts and not to determine eligibility; 2.) HCFA modifies the headers and language on this form to be consistent with the language and headers on HCFA-2744 so items 4A-5A, 4B-5B, 14-25, and 30-33 can be used to derive aggregate facility data currently on the HCFA-2744 form; and 3.) HCFA will evaluate the practical utility of the data being collected on this form to ensure that all data elements being collected are consistent with HCFA's proposed ESRD Conditions for Coverage of End Stage Renal Disease Facilites regulation and its new core data set.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/1997	08/31/1997
Responses	60,000	0	0
Time Burden (Hours)	25,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The form captures the necessary medical information required to determine Medicare eligibility of an end-stage renal disease claimant. It also captures the specific medical data required for research and policy decisions on this population as required by law.

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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
End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration	HCFA-2728(ESRD)

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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	60,000	0	0	60,000	0	0
Annual Time Burden (Hours)	25,000	0	0	25,000	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: 07/02/1996

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