HOME HEALTH AGENCY REPORT AND BILLING

ICR 198108-0938-005

OMB: 0938-0012

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
112501 Migrated
ICR Details
0938-0012 198108-0938-005
Historical Active 198107-0938-008
HHS/CMS
HOME HEALTH AGENCY REPORT AND BILLING
Revision of a currently approved collection   No
Regular
Approved without change 10/15/1981
Retrieve Notice of Action (NOA) 08/21/1981
  Inventory as of this Action Requested Previously Approved
10/31/1982 10/31/1982 07/31/1984
3,124,800 0 3,125,621
520,800 0 520,937
0 0 0

THIS IS THE BASIC ADMISSION AND BILLING FORM FOR COVERED HOME HEALTH AGENCY SERVICES RENDERED TO MEDICARE BENEFICIARIES, AND ALSO IS USED T UPDATE BENEFICIARIES UTILIZATON RECORDS.

None
None


No

1
IC Title Form No. Form Name
HOME HEALTH AGENCY REPORT AND BILLING HCFA-1487

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 3,124,800 3,125,621 0 0 -821 0
Annual Time Burden (Hours) 520,800 520,937 0 0 -137 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
08/21/1981


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