View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 0938-0251	ICR Reference No: 200408-0938-003
Status: Historical Active	Previous ICR Reference No: 200107-0938-014
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Application for Hospital Insurance and Supporting Regulations in 42 CFR 406.7
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: 09/17/2004
	Date Received in OIRA: 08/20/2004
Terms of Clearance: This information collection is approved with the following terms of clearance. Prior to printing additional stock of the Spanish language form, CMS will change the form name to CMS-18F5-SP and will change all references to HCFA to CMS in the form.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2007	09/30/2007	09/30/2004
Responses	50,000	0	50,000
Time Burden (Hours)	12,500	0	12,500
Cost Burden (Dollars)	0	0	0

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