Information Collection

Outpatient Physical Therapy Speech Pathology Survey Report and Supporting Regulation in 42 CFR 485.701-485.729

IC 7822 under ICR 201408-0938-005 · OMB 0938-0065.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0065 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-1856 Outpatient Physical Therapy Speech Pathology Survey Report and Supporting Regulation in 42 CFR 485.701-485.729 Form and Instruction
CMS-1856 Request for Certification in the Medicare and/or Medicai Form CMS-1856.pdf Form and Instruction
CMS-1893 OUTPATIENT PHYSICAL THERAPY — SPEECH PATHOLOGY SURVEY RE CMS1893.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Outpatient Physical Therapy Speech Pathology Survey Report and Supporting Regulation in 42 CFR 485.701-485.729	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 485.701-485.729

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1856	Request for Certification in the Medicare and/or Medicaid Program	Form CMS-1856.pdf		No	No	Fillable Printable
Form and Instruction	CMS-1893	OUTPATIENT PHYSICAL THERAPY â SPEECH PATHOLOGY SURVEY REPORT	CMS1893.pdf		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 700	Number of Respondents for Small Entity: 300

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	700	205	495
Annual IC Time Burden (Hours)	613	-253	866
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.