Information Collection

(Home Health Agencies) Survey of Access to Home Health Services for Medicare Beneficiaries

IC 202896 under ICR 201206-0938-009 · OMB 0938-1183.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10429 (Home Health Agencies) Survey of Access to Home Health Services for Medicare Beneficiaries	Form
HHSC_HHA cover letter 03292012_508.pdf	Other-Cover Letter
HHSC_HHA postcard text 04122012_508.pdf	Other-Post Card
HHSC_HHA prenotice letter 03292012_508.pdf	Other-Letter
HHSC_Prompting script 03292012_508.pdf	Instruction
CMS-10429 (Home Health Agencies) Survey of Access to Home Health S HHSC_HHA Survey [rev 6-27-20012].pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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
Form	CMS-10429	(Home Health Agencies) Survey of Access to Home Health Services for Medicare Beneficiaries	HHSC_HHA Survey [rev 6-27-20012].pdf	No	No	Fillable Printable
Other-Cover Letter			HHSC_HHA cover letter 03292012_508.pdf	No	No	Printable Only
Other-Post Card			HHSC_HHA postcard text 04122012_508.pdf	No	No	Printable Only
Other-Letter			HHSC_HHA prenotice letter 03292012_508.pdf	No	No	Printable Only
Instruction			HHSC_Prompting script 03292012_508.pdf	No	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 600

Number of Respondents for Small Entity: 540

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	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.