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 201710-0938-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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 09-26-2017.pdf	Form and Instruction

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 09-26-2017.pdf		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 851

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	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	851	-317	1,168
Annual IC Time Burden (Hours)	213	-79	292
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.