Assurance of Compliance

Assurance and Certification of Compliance (NPRM)

Documents and Forms

Document Name Document Type
Form HHS Form 690 Assurance of Compliance Form and Instruction
HHS Form 690 Assurance of Compliance Revised 690 form.docx www.hhs.gov/civil-rights/for-providers/clearance-medicare-providers/index.html Form and Instruction
HHS Form 690 Assurance of Compliance Revised 690 form.docx www.hhs.gov/civil-rights/for-providers/clearance-medicare-providers/index.html Form and Instruction

Information Collection (IC) Details

IC Title:	Assurance of Compliance	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	HHS Form 690	Assurance of Compliance	Revised 690 form.docx	https://www.hhs.gov/civil-rights/for-providers/clearance-medicare-providers/index.html	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,595	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	9,595	-500,290	9,595	500,290
Annual IC Time Burden (Hours)	38,380	-2,501,450	38,380	2,501,450
Annual IC Cost Burden (Dollars)	0	0	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.