Plan Of Treatment And Home Health Certification Form, Medical Information Form, Addendum To The Pot And Mif For, And Intermediary Medical Information Request

PLAN OF TREATMENT AND HOME HEALTH CERTIFICATION FORM, MEDICAL INFORMATION FORM, ADDENDUM TO THE POT AND MIF FOR, AND INTERMEDIARY MEDICAL INFORMATION REQUEST

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0357 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:	PLAN OF TREATMENT AND HOME HEALTH CERTIFICATION FORM, MEDICAL INFORMATION FORM, ADDENDUM TO THE POT AND MIF FOR, AND INTERMEDIARY MEDICAL INFORMATION REQUEST	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
Annual Number of Responses for this IC	2,654,386	2,654,386
Annual IC Time Burden (Hours)	1,216,599	1,216,599
Annual IC Cost Burden (Dollars)	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.