4120-01-U-P
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[Document Identifiers: CMS-370 and CMS-377]
Agency Information Collection Activities: Proposed Collection; Comment Request
AGENCY: Centers for Medicare & Medicaid Services, Health and Human Services (HHS).
ACTION: Notice.
SUMMARY: The Centers for Medicare & Medicaid Services (CMS) is announcing an
opportunity for the public to comment on CMS’ intention to collect information from the public.
Under the Paperwork Reduction Act of 1995 (PRA), Federal agencies are required to publish
notice in the Federal Register concerning each proposed collection of information (including
each proposed extension or reinstatement of an existing collection of information) and to allow
60 days for public comment on the proposed action. Interested persons are invited to send
comments regarding our burden estimates or any other aspect of this collection of information,
including the necessity and utility of the proposed information collection for the proper
performance of the agency’s functions, the accuracy of the estimated burden, ways to enhance
the quality, utility, and clarity of the information to be collected, and the use of automated
collection techniques or other forms of information technology to minimize the information
collection burden.
DATES: Comments must be received by [INSERT DATE 60 DAYS AFTER DATE OF
PUBLICATION IN THE FEDERAL REGISTER].
ADDRESSES: When commenting, please reference the document identifier or OMB control
number. To be assured consideration, comments and recommendations must be submitted in any
one of the following ways:

1. Electronically. You may send your comments electronically to
http://www.regulations.gov. Follow the instructions for "Comment or Submission" or "More
Search Options" to find the information collection document(s) that are accepting comments.
2. By regular mail. You may mail written comments to the following address:
CMS, Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development
Attention: Document Identifier/OMB Control Number: 
Room C4-26-05
7500 Security Boulevard
Baltimore, Maryland 21244-1850.
To obtain copies of a supporting statement and any related forms for the proposed
collection(s) summarized in this notice, please access the CMS PRA web site by copying and
pasting the following web address into your web browser: https://www.cms.gov/Regulationsand-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing
FOR FURTHER INFORMATION CONTACT: William N. Parham at (410) 786-4669.
SUPPLEMENTARY INFORMATION:
Contents
This notice sets out a summary of the use and burden associated with the following
information collections. More detailed information can be found in each collection’s supporting
statement and associated materials (see ADDRESSES).
CMS-370 and CMS-377 ASC Forms for Medicare Program Certification
Under the PRA (44 U.S.C. 3501-3520), Federal agencies must obtain approval from the
Office of Management and Budget (OMB) for each collection of information they conduct or
sponsor. The term "collection of information" is defined in 44 U.S.C. 3502(3) and 5 CFR
1320.3(c) and includes agency requests or requirements that members of the public submit
reports, keep records, or provide information to a third party. Section 3506(c)(2)(A) of the PRA

requires Federal agencies to publish a 60-day notice in the Federal Register concerning each
proposed collection of information, including each proposed extension or reinstatement of an
existing collection of information, before submitting the collection to OMB for approval. To
comply with this requirement, CMS is publishing this notice.
Information Collection
1. Type of Information Collection Request: Extension of a currently approved collection;
Titles of Information Collection: ASC Forms for Medicare Program Certification; Use: The
form CMS-370 titled “Health Insurance Benefits Agreement” is used for the purpose of
establishing an ASC’s eligibility for payment under title XVIII of the Social Security Act (the
“Act”). This agreement, upon acceptance by the Secretary of Health & Human Services, shall be
binding on the ASC and the Secretary. The agreement may be terminated by either party in
accordance with regulations. In the event of termination of this agreement, payment will not be
available for the ASC’s services furnished to Medicare beneficiaries on or after the effective date
of termination.
The CMS-377 form is used by ASCs to initiate both the initial and renewal survey by the
State Survey Agency, which provides the certification required for an ASC to participate in the
Medicare program. An ASC must complete the CMS-377 form and send it to the appropriate
State Survey Agency prior to their scheduled accreditation renewal date. The CMS-377 form
provides the State Survey Agency with information about the ASC facility’s characteristics, such
as, determining the size and the composition of the survey team on the basis of the number of
ORs/procedure rooms and the types of surgical procedures performed in the ASC. Form
Numbers: CMS-370 and CMS-377 (OMB control number: 0938-0266); Frequency:
Occasionally; Affected Public: Private Sector - Business or other for-profit and Not-for-profit
institutions; Number of Respondents: 1,711; Total Annual Responses: 1,711; Total Annual
Hours: 1,559. (For policy questions regarding this collection contact Caroline Gallaher at 410786-8705.)

William N. Parham, III
Director,
Division of Information Collections and Regulatory Impacts,
Office of Strategic Operations and Regulatory Affairs.
[FR Doc. 2024-13129 Filed: 6/13/2024 8:45 am; Publication Date: 6/14/2024]