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: 0938-1029	ICR Reference No: 200707-0938-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Worksheet for Recording Results of Medicare Site Visits of Independent Diagnostic Testing Facilities (IDTFs)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/30/2007
	Date Received in OIRA: 07/13/2007
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2010	36 Months From Approved
Responses	2,000	0	0
Time Burden (Hours)	4,000	0	0
Cost Burden (Dollars)	0	0	0

Authorizing Statute(s): PL: Pub.L. 105 - 33 4313 Name of Law: BBA of 1997
   PL: Pub.L. 104 - 134 31001 Name of Law: the Debt Collection Improvement Act of 1996
   US Code: 42 USC 1395f Name of Law: Requirement of Requests and Certifications
   US Code: 42 USC 1395g Name of Law: PAYMENT TO PROVIDERS OF SERVICES
   US Code: 42 USC 1395l Name of Law: Payment of Benefits
   US Code: 42 USC 1395u Name of Law: PROVISIONS RELATING TO THE ADMINISTRATION OF PART B
   US Code: 42 USC 1395m Name of Law: SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
   US Code: 42 USC 1395cc Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES

Citations for New Statutory Requirements: None

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	2,000	2,000
Annual Time Burden (Hours)	4,000	4,000
Annual Cost Burden (Dollars)	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This is a new information collection request. Per 42 CFR 410.33, any IDTF that wishes to enroll in the Medicare program must undergo a site visit. The purpose of the site visit is to ensure that the IDTF is in compliance with the provisions of 42 CFR 410.33, as well as all other applicable Federal, State and local laws and regulations. It is also used to verify the information the IDTF furnished on its CMS-855B enrollment application.

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