Information Collection

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

IC 113521 under ICR 199007-0938-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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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Information Collection (IC) Details

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

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,700	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,825,000	3,606,073	3,218,927
Annual IC Time Burden (Hours)	1,706,250	230,908	1,475,342
Annual IC Cost Burden (Dollars)	0	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.