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OMB Control No: 0938-1111	ICR Reference No: 201310-0938-002
Status: Historical Active	Previous ICR Reference No: 201009-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: 20696
Title: Electronic Submission of Medicare GME Affiliation Agreements
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 without change	Conclusion Date: 04/21/2014
	Date Received in OIRA: 10/25/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2017	36 Months From Approved	04/30/2014
Responses	375	0	375
Time Burden (Hours)	166	0	166
Cost Burden (Dollars)	0	0	0

Abstract: As discussed in the FY2011 Inpatient Prospective Payment System final rule, we will allow hospitals to electronically submit the copy of the affiliation agreement that is required to be sent to the CMS Central Office. The electronic submission process consists of either an email mailbox or a Web site where hospitals must submit their Medicare GME affiliation agreements to the CMS Central Office to a designated online mailbox. A copy of the Medicare GME affiliation agreement must be received through the electronic system no later than 11:59 p.m. on July 1 of each academic year. The electronic affiliation agreement must be submitted either as a scanned copy or a Printer-Friendly Display (PDF) version of that hard copy agreement; we will not accept an agreement in any electronic format that could be subject to manipulation. The scanned and/or PDF format will enable CMS to ensure that the agreements are signed and dated as required in the regulations at 42 CFR 413.75. Hospitals will have the option to continue to submit a hard copy of its affiliation agreement to the CMS Central Office. In addition, each fiscal intermediary or MAC will continue to have the authority to specify its requirements for submittal of the Medicare GME affiliation agreement by hospitals that are part of the affiliation.

Authorizing Statute(s): PL: Pub.L. 105 - 32 4623 Name of Law: Limitation of Number of Residents and Rolling Average FTE Count
US Code: 42 USC 1395ww Name of Law: Payment to Hospitals for Inpatient Hospital Services

Citations for New Statutory Requirements: None

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

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 45205	07/26/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 61846	10/04/2013
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Development of Agreement	CMS-10326
Electronic Submission to CMS	CMS-10326
Hardcopy Submission to FI or MAC	CMS-10326

ICR Summary of Burden

	Total Approved	Previously Approved
Annual Number of Responses	375	375
Annual Time Burden (Hours)	166	166
Annual Cost Burden (Dollars)	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:

Annual Cost to Federal Government: $5,972

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov

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