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Federal forms, ICRs, and supporting documents

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Hospice Request for Certification in the Medicare Program and Supporting Regulations contained in 42 CFR Part 489.11 and 489.20

IC 7960 under ICR 201401-0938-017 · OMB 0938-0313.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Hospice Request for Certification in the Medicare Program and Supporting Regulations contained in 42 CFR Part 489.11 and 489.20
 
No Modified
 
Mandatory
 
42 CFR 489.11-489.20

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-417 Hospice Request for Certification in the Medicare Program CMS-417-rev_508_Compliant.pdf No No Fillable Fileable

Health Health Care Services

 

1,168 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,168 0 -2,326 0 0 3,494
Annual IC Time Burden (Hours) 292 0 -582 0 0 874
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk 417 Crosswalk.pdf 01/29/2014
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.