Information Collection

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.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0313 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-417 Hospice Request for Certification in the Medicare Program and Supporting Regulations contained in 42 CFR Part 489.11 and 489.20	Form and Instruction
CMS-417 Hospice Request for Certification in the Medicare Progra CMS-417-rev_508_Compliant.pdf	Form and Instruction
417 Crosswalk.pdf Crosswalk	IC Document

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 489.11-489.20

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
Form and Instruction	CMS-417	Hospice Request for Certification in the Medicare Program	CMS-417-rev_508_Compliant.pdf		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,168

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,168	-2,326	3,494
Annual IC Time Burden (Hours)	292	-582	874
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.