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Federal forms, ICRs, and supporting documents

Information Collection Request

Medicare Participating Physician or Supplier Agreement -- HCFA-460

ICR 199907-0938-007 · OMB 0938-0373 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
8012 Medicare Participating Physician or Supplier Agreement -- HCFA-460 Form Migrated
ICR Details
0938-0373 199907-0938-007
Historical Active 199606-0938-011
HHS/CMS
Medicare Participating Physician or Supplier Agreement -- HCFA-460
Extension without change of a currently approved collection   No
Regular
Approved without change 10/05/1999
Retrieve Notice of Action (NOA) 07/14/1999
  Inventory as of this Action Requested Previously Approved
10/31/2002 10/31/2002 09/30/1999
45,000 0 70,000
11,250 0 17,500
0 0 0
The HCFA-460 is completed by nonparticipating physicians and suppliers if they choose to participate in Medicare part B. By signing the agreement, the physician or supplier agrees to take assignment on all Medicare claims. To take assignment means to accept the Medicare allowed amount as payment in full for the services they furnish and to charge the beneficiary no more than the deductible and coinsurance for the covered service. In exchange for signing the agreement, the physician or supplier receives a significant number of program benefits not available to nonparticipating suppliers.
None
None
No
1
IC Title Form No. Form Name
Medicare Participating Physician or Supplier Agreement -- HCFA-460 HCFA-460
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 45,000 70,000 0 0 -25,000 0
Annual Time Burden (Hours) 11,250 17,500 0 0 -6,250 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
07/14/1999