Home Health Agency Medical Information Form, And Intermediary Medical Information Request Form

HOME HEALTH AGENCY MEDICAL INFORMATION FORM, AND INTERMEDIARY MEDICAL INFORMATION REQUEST FORM

OMB: 0938-0357

IC ID: 113516

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HOME HEALTH AGENCY MEDICAL INFORMATION FORM, AND INTERMEDIARY MEDICAL INFORMATION REQUEST FORM
 
No Migrated
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form HCFA 443 No No
Form 444 No No


    

4,000 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,654,386 0 0 2,654,386 0 0
Annual IC Time Burden (Hours) 1,166,599 0 0 1,166,599 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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