Hospice Request for Certification in the Medicare Program and Supporting Regulations contained in 42 CFR Part 489.11 and 489.20

ICR 200708-0938-007

OMB: 0938-0313

Federal Form Document

ICR Details
0938-0313 200708-0938-007
Historical Active 200405-0938-007
HHS/CMS
Hospice Request for Certification in the Medicare Program and Supporting Regulations contained in 42 CFR Part 489.11 and 489.20
Extension without change of a currently approved collection   No
Regular
Approved without change 12/27/2007
Retrieve Notice of Action (NOA) 08/22/2007
  Inventory as of this Action Requested Previously Approved
12/31/2010 36 Months From Approved 12/31/2007
2,286 0 2,286
572 0 572
0 0 0

The Hospice Request for Certification Form is the identification and screening form used to initiate the certification process and to determine if the provider has sufficient personnel to participate in the Medicare program.

US Code: 42 USC 418 Name of Law: Hospice Care
   PL: Pub.L. 97 - 248 1861 Name of Law: Social Security Act
  
None

Not associated with rulemaking

  72 FR 25318 05/04/2007
72 FR 46085 08/16/2007
No

  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 2,286 2,286 0 0 0 0
Annual Time Burden (Hours) 572 572 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$5,160
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Melissa Musotto 4107866962

  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.
08/22/2007


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