Information Collection

Medicare - Plan Of Treatment & Home Health Certification, Medical Information, Addendum To The Plan Of Treatment & Medical Information, & Intermediary Med. Infor. Request

IC 113519 under ICR 198707-0938-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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Document Name	Document Type

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Information Collection (IC) Details

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IC Title:

MEDICARE - PLAN OF TREATMENT & HOME HEALTH CERTIFICATION, MEDICAL INFORMATION, ADDENDUM TO THE PLAN OF TREATMENT & MEDICAL INFORMATION, & INTERMEDIARY MED. INFOR. 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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	486, 487,	No	No
Form	HCFA-485,	No	No
Form	488	No	No

Federal Enterprise Architecture Business Reference Module

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,903

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,218,927	564,541	2,654,386
Annual IC Time Burden (Hours)	1,475,342	258,743	1,216,599
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

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

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