Hospice Request for Certification in the Medicare Program and Supporting Regulations

ICR 201401-0938-017

OMB: 0938-0313

Federal Form Document

ICR Details
0938-0313 201401-0938-017
Historical Active 201012-0938-011
HHS/CMS 21373
Hospice Request for Certification in the Medicare Program and Supporting Regulations
Revision of a currently approved collection   No
Regular
Approved without change 09/30/2014
Retrieve Notice of Action (NOA) 01/31/2014
  Inventory as of this Action Requested Previously Approved
09/30/2017 36 Months From Approved 09/30/2014
1,168 0 3,494
292 0 874
0 0 0

The Hospice Request for Certification Form is the identification and screening form used to initiate the certification process and to determine if the provider has sufficient personnel to participate in the Medicare program.

US Code: 42 USC 418 Name of Law: Hospice Care
   PL: Pub.L. 97 - 248 1861 Name of Law: Social Security Act
  
None

Not associated with rulemaking

  78 FR 65656 11/01/2013
79 FR 4726 01/29/2014
No

  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 1,168 3,494 0 -2,326 0 0
Annual Time Burden (Hours) 292 874 0 -582 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Miscellaneous Actions
The burden is reduced to include only those hospices involved in initial or recertification, rather than all hospices. In 2013, this included 1,168 hospices

$0
No
No
No
No
No
Uncollected
Denise King 410 786-1013 [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.
01/31/2014


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