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Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Provider Supplier)

IC 185564 under ICR 201512-0938-001 · OMB 0938-0950.

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Form and Instruction
Form and Instruction
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IC Document
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Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Provider Supplier)
 
No Modified
 
Voluntary
 
42 CFR 405.910

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-1696 Nombramiento de un Representante Clean_2015_CMS_1696_version508_Spanish112515.docx Yes No Fillable Fileable

Health Health Care Services

 

366,656 0
   
Private Sector Businesses or other for-profits
 
   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 366,656 0 0 0 0 366,656
Annual IC Time Burden (Hours) 91,664 0 0 0 0 91,664
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk Crosswalk_CMS1696 Spanish.xlsx 12/01/2015
Track Changes Redline_2015_CMS_1696_version508_Spanish112515.docx 12/01/2015
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