View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0938-0266	ICR Reference No: 202102-0938-002
Status: Historical Active	Previous ICR Reference No: 201707-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report (CMS-377; CMS-370)
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: 07/07/2021
	Date Received in OIRA: 02/04/2021
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2024	36 Months From Approved	07/31/2021
Responses	1,567	0	1,888
Time Burden (Hours)	1,012	0	1,371
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	1,567	1,888	-321
Annual Time Burden (Hours)	1,012	1,371	-359
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: We believe that the increase in total burden cost is due to several factors. First, for the CMS-370 form, the number of new ASC respondents increased from 170 to 228 based on the current statistics about the average number of new ASCs are established per year. Also, the wage rates were updated. There was a decrease in burden hours from 1,371 to 1,012 because of a decrease in time of completing the forms.

Annual Cost to Federal Government: $59,584

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]? 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? No

Agency Contact: Denise King 410 786-1013 Denise.King@cms.hhs.gov

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