View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0938-1133	ICR Reference No: 201709-0938-003
Status: Historical Active	Previous ICR Reference No: 201406-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-10332 (CM/CCPG/DTPC)
Title: Disclosure Requirement for the In-Office Ancillary Services Exception (CMS-10332)
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: 01/02/2018
	Date Received in OIRA: 09/21/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2021	36 Months From Approved	01/31/2018
Responses	273,774	0	761,676
Time Burden (Hours)	17,881	0	19,638
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	273,774	761,676	-487,902
Annual Time Burden (Hours)	17,881	19,638	-1,757
Annual Cost Burden (Dollars)	0	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: The burden estimates have been updated to reflect changes in the number of physicians, the number of disclosures, and the hourly wages of the personnel preparing and delivering the disclosure. However, we have made no changes to the information being collected.

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

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: William Parham 4107864669

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