Information Collection

Hospice Cost Report and Supporting Regulations in 42 CFR 413.20 and 413.24

IC 8476 under ICR 201312-0938-003 · OMB 0938-0758.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0758 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
R1p243 [rev 11-22-2013].doc	Instruction
CMS-1984-14 Hospice Cost Report R1p243f.pdf	Form
CMS-1984-14-Revisions Crosswalk from old to new.doc Crosswalk	IC Document

IC Title:

Hospice Cost Report and Supporting Regulations in 42 CFR 413.20 and 413.24

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 413.24 42 CFR 413.20

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
Instruction			R1p243 [rev 11-22-2013].doc		Yes	No	Fillable Printable
Form	CMS-1984-14	Hospice Cost Report	R1p243f.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,751

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,751	0	448	2,303
Annual IC Time Burden (Hours)	517,188	896	110,964	405,328
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	CMS-1984-14-Revisions Crosswalk from old to new.doc	11/22/2013

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