Information Collection

Notice

IC 206099 under ICR 201303-0938-009 · OMB 0938-1196.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1196 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10280 Notice	Form
CMS-10280_HHCCNForm InstructionsOct2012v508.pdf	Instruction
CMS-10280 Home Health Change of Care Notice CMS-10280_Instrument.pdf	Form

IC Title:

Notice

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 484.10

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10280	Home Health Change of Care Notice	CMS-10280_Instrument.pdf		Yes	No	Fillable Fileable
Instruction			CMS-10280_HHCCNForm InstructionsOct2012v508.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,914

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: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	14,126,428	14,126,428
Annual IC Time Burden (Hours)	941,385	941,385
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.