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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0313 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-417 Hospice Request for Certification in the Medicare Program and Supporting Regulations contained in 42 CFR Part 489.11 and 489.20 Form and Instruction
CMS-417 Hospice Request for Certification in the Medicare Progra CMS-417-r.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Hospice Request for Certification in the Medicare Program and Supporting Regulations contained in 42 CFR Part 489.11 and 489.20	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 489.11-489.20

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-417	Hospice Request for Certification in the Medicare Program	CMS-417-r.pdf		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,494	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	3,494	1,208	2,286
Annual IC Time Burden (Hours)	874	302	572
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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