Information Collection

Home Health Agency Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, 413.106

IC 7766 under ICR 200704-0938-007 · OMB 0938-0022.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0022 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-1728-94 pr2_3290_exhibit_1.doc	Instruction
CMS-1728-94 pr2_32_toc.doc	Instruction
CMS-1728-94 pr2_3200_to_3215.2.doc	Instruction
CMS-1728-94 pr2_3215.3_to_3238.doc	Instruction
CMS-1728-94 pr2_3295.doc	Instruction
CMS-1728-94 HOME HEALTH AGENCY COST REPORT CERTIFICATION AND SETTLEM CMS-1728-94 r121728f.xls	Form

IC Title:

Home Health Agency Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, 413.106

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 413.24 42 CFR 413.20 42 CFR 413.106

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-1728-94 pr2_3215.3_to_3238.doc	Yes	Yes	Paper Only
Instruction			CMS-1728-94 pr2_3295.doc	Yes	Yes	Paper Only
Instruction			CMS-1728-94 pr2_32_toc.doc	Yes	Yes	Paper Only
Instruction			CMS-1728-94 pr2_3200_to_3215.2.doc	Yes	Yes	Paper Only
Instruction			CMS-1728-94 pr2_3290_exhibit_1.doc	Yes	Yes	Paper Only
Form	CMS-1728-94	HOME HEALTH AGENCY COST REPORT CERTIFICATION AND SETTLEMENT SUMMARY	CMS-1728-94 r121728f.xls	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,069

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,069	-2,241	7,310
Annual IC Time Burden (Hours)	892,144	-418,916	1,311,060
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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