HOME HEALTH AGENCY REPORT AND BILLING

ICR 198212-0938-002

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
112503 Migrated
ICR Details
0938-0012 198212-0938-002
Historical Active 198210-0938-002
HHS/CMS
HOME HEALTH AGENCY REPORT AND BILLING
Revision of a currently approved collection   No
Regular
Approved without change 01/27/1983
Retrieve Notice of Action (NOA) 12/02/1982
  Inventory as of this Action Requested Previously Approved
01/31/1986 01/31/1986 10/31/1983
4,171,200 0 4,171,200
695,200 0 695,200
0 0 0

THIS IS THE BASIC MEDICARE BILLING FORM FOR COVERED HOME HEALTH SERVIC RENDERED BY HOME HEALTH AGENCIES UNDER THE SOCIAL SECURITY ACT.

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 4,171,200 4,171,200 0 0 0 0
Annual Time Burden (Hours) 695,200 695,200 0 0 0 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.
12/02/1982


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