Information Collection

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

IC 113518 under ICR 198702-0938-003 · OMB 0938-0357.

⚠️ Notice: This information collection may be referencing outdated material.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

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Information Collection (IC) Details

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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.