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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1856 Request for Certification in the Medicare and/or Medicaid Program Outpatient Physical Therapy Speech Pathology Survey Report and Supporting Regulation in 42 CFR 485.701-485.729	Form and Instruction
Form CMS-1893 OUTPATIENT PHYSICAL THERAPY — SPEECH PATHOLOGY SURVEY REPORT 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

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:

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-1856				No	No	Fillable Printable
Form and Instruction	CMS-1893				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 %

table that charts list of burden
	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

table that charts IC Documents
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.

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