HOSPICE COST REPORT AND DATA FORM

ICR 198903-0938-001

OMB: 0938-0392

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
113644 Migrated
ICR Details
0938-0392 198903-0938-001
Historical Active 198901-0938-001
HHS/CMS
HOSPICE COST REPORT AND DATA FORM
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 03/20/1989
Retrieve Notice of Action (NOA) 03/02/1989
Approved for use through 9/90 under the condition that the next form submitted for OMB clearance is revised to contain the burden disclosure statement as required by 5 CFR 1320.
  Inventory as of this Action Requested Previously Approved
09/30/1990 09/30/1990
157 0 0
50,083 0 0
0 0 0

THIS FORM MUST BE COMPLETED ANNUALLY BY THE FREE-STANDING HOSPICE WHIC ARE CERTIFIED TO PARTICIPATE IN MEDICARE. IT IS CALLED A COST REPORT BECAUSE IT COLLECTS COST DATA. IT WILL NOT, HOWEVER BE USED FOR RETROSPECTIVE COST SETTLEMENT. RATHER, THE COST DATA WILL BE USED TO UPDATE THE NATIONAL REIMBURSEMENT RATE APPLIED TO FREE-STANDING HOSPICES.

None
None


No

1
IC Title Form No. Form Name
HOSPICE COST REPORT AND DATA FORM HCFA-1984

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 157 0 0 157 0 0
Annual Time Burden (Hours) 50,083 0 0 50,083 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
03/02/1989


© 2024 OMB.report | Privacy Policy