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Federal forms, ICRs, and supporting documents

Information Collection

Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form

IC 7777 under ICR 201405-0938-002 · OMB 0938-0027.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 486.100

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-1880 Request for Certification as a Supplier of Portable X-ray Services CMS 1880 Request For Certification.pdf Yes No Fillable Printable
Form and Instruction CMS-1882 Portable X-ray Survey Report CMS-1882_Rev_2014.pdf Yes No Fillable Printable

Health Health Care Services

 

579 0
   
State, Local, and Tribal Governments
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 86 0 0 0 0 86
Annual IC Time Burden (Hours) 151 0 0 0 0 151
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.