Hospice Survey and Deficiencies Report Form (CMS-643)

ICR 201207-0938-003

OMB: 0938-0379

Federal Form Document

Forms and Documents
IC Document Collections
IC ID
Document
Title
Status
8022 Modified
ICR Details
0938-0379 201207-0938-003
Historical Active 200906-0938-005
HHS/CMS
Hospice Survey and Deficiencies Report Form (CMS-643)
Extension without change of a currently approved collection   No
Regular
Approved without change 09/18/2012
Retrieve Notice of Action (NOA) 07/18/2012
  Inventory as of this Action Requested Previously Approved
09/30/2015 36 Months From Approved 09/30/2012
1,217 0 1,130
1,217 0 1,130
0 0 0

In order to participate in the Medicare program, a hospice must meet certain Federal health and safety conditions of participation. This form will be used by State surveyors to record data about a hospice's compliance with these conditions of participation in order to initiate the certification or recertification process.

US Code: 42 USC 488.26 Name of Law: Determining Compliance
   US Code: 42 USC 442.30 Name of Law: Agreement as evidence of Certification
  
None

Not associated with rulemaking

  77 FR 27777 05/11/2012
77 FR 42316 07/18/2012
No

1
IC Title Form No. Form Name
Hospice Survey and Deficiencies Report Form (CMS-643) CMS-643 Hospice Survey and Deficiencies Report

  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 1,217 1,130 0 0 87 0
Annual Time Burden (Hours) 1,217 1,130 0 0 87 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
No
No
No
Uncollected
Mitch Bryman 410 786-5258 [email protected]

  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.
07/18/2012


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