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Patient Intake Data Form For The National Home Health Agency Prospective Payment Demonstration

IC 114003 under ICR 199311-0938-005 · OMB 0938-0570.

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PATIENT INTAKE DATA FORM FOR THE NATIONAL HOME HEALTH AGENCY PROSPECTIVE PAYMENT DEMONSTRATION
 
No Migrated
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form HHA-442 No No


    

46,500 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 46,500 0 46,500 0 0 0
Annual IC Time Burden (Hours) 46,655 0 46,655 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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