Hospice Statements Of Reimbursements

HOSPICE STATEMENTS OF REIMBURSEMENTS

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	HOSPICE STATEMENTS OF REIMBURSEMENTS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

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: 30	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	150	30	120
Annual IC Time Burden (Hours)	3,105	381	2,724
Annual IC Cost Burden (Dollars)	0	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.