Information Collection

Plan Of Treatment (pot) & Home Health Certification Form, Hcfa-485 Medical Information Form (mif), Hcfa-486 Addendum To The Pot & Mif, Hcfa-487, & Intermediary Med., Hcfa-488

IC 113517 under ICR 198504-0938-001 · OMB 0938-0357.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0357 can be found here:

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Information Collection (IC) Details

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IC Title:	PLAN OF TREATMENT (POT) & HOME HEALTH CERTIFICATION FORM, HCFA-485 MEDICAL INFORMATION FORM (MIF), HCFA-486 ADDENDUM TO THE POT & MIF, HCFA-487, & INTERMEDIARY MED., HCFA-488	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-485,	No	No
Form	486, 487,	No	No
Form	488	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,320	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	1	-2,654,385	2,654,386
Annual IC Time Burden (Hours)	1	-1,216,598	1,216,599
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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