Fax to Determine Provider Status

Promotion of the National Amyotrophic Lateral Sclerosis (ALS) Registry to Non-referral Centers

Documents and Forms

Document Name Document Type
Fax to Determine Provider Status Form and Instruction
Fax Cover Sheet to Determine Provider Status - Promotion AppndxB Fax Cover Dtrmn Provdr Status.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Fax to Determine Provider Status	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Fax Cover Sheet to Determine Provider Status - Promotion of the National ALS Registry to Non-referral Centers	AppndxB Fax Cover Dtrmn Provdr Status.docx	NA	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 380	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	380	380
Annual IC Time Burden (Hours)	6	6
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.