Information Collection

Hospice Statements Of Reimbursements

IC 113035 under ICR 198107-0938-004 · OMB 0938-0177.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0177 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	HOSPICE STATEMENTS OF REIMBURSEMENTS	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.	Available Electronically?	Can Be Submitted Electronically?
Form	HCFA-278	No	No
Form	278Q	No	No
Form	279,279Q	No	No
Form	280, 280Q	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 26	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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	2,724	2,724
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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