Information Collection

Home Health Agency Report And Billing Form

IC 166036 under ICR 197803-0938-013 · OMB 0938-0012.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	HOME HEALTH AGENCY REPORT AND BILLING FORM	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-1487				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,700,000	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,700,000	1,400,000	1,300,000
Annual IC Time Burden (Hours)	450,000	233,334	216,666
Annual IC Cost Burden (Dollars)	0	0	0

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Title	Document	Date Uploaded

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