Attending Physicians Statement and Documentation of Medicare Emergency and Supporting Regulations in 42 CFR Section 424.103

Forms and Documents

Document Name	Status
Form CMS-1771 Attending Physicians Statement and Documentation of Medicare Emergency and Supporting Regulations in 42 CFR Section 424.103 Form and Instruction	Modified
CMS-1771 SupportingStatementPart[1]_1.11.08.doc Supporting Statement A	2008-04-29

IC Document Collections

IC ID	Document Title	Status
7770	Attending Physicians Statement and Documentation of Medicare Emergency and Supporting Regulations in 42 CFR Section 424.103 Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0023	ICR Reference No: 200805-0938-008
Status: Historical Active	Previous ICR Reference No: 200504-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Attending Physicians Statement and Documentation of Medicare Emergency and Supporting Regulations in 42 CFR Section 424.103
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/15/2008
	Date Received in OIRA: 05/19/2008
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2011	36 Months From Approved	08/31/2008
Responses	200	0	200
Time Burden (Hours)	50	0	50
Cost Burden (Dollars)	0	0	0

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Abstract: 42 CFR 424.103 (b) requires that before a nonparticipating hospital may be paid for emergency services rendered to a Medicare beneficiary, a statement must be submitted that is sufficiently comprehensive to support that an emergency existed. Form CMS-1771 contains a series of questions relating to the medical necessity of the emergency. The attending physician must attest that the hospitalization was required under the regulatory emergency definition (42 CFR 424.101 attached) and give clinical documentation to support the claim.

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Authorizing Statute(s): Statute at Large: 18 Stat. 1814 Name of Statute: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 7560	02/08/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 22418	04/25/2008
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
Attending Physicians Statement and Documentation of Medicare Emergency and Supporting Regulations in 42 CFR Section 424.103	CMS-1771	Attending Physicians Statement and Documentation of Medicare Emergency

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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	200	200	0	0	0	0
Annual Time Burden (Hours)	50	50	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

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: $993

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: 05/19/2008

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