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GenIC #54 - Electronic Visit Verification (EVV) Good Faith Effort Exemption Requests

IC 233660 under ICR 201712-0938-019 · OMB 0938-1148.

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Form and Instruction
Form and Instruction
Form and Instruction
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GenIC #54 - Electronic Visit Verification (EVV) Good Faith Effort Exemption Requests CMCS
 
New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10398 #54 EVV Good Faith Effort Request Form (Home Health Care Services) 54 - EVV Good Faith Effort Exemption Requests GFE-HHCS-Template3 (rev OSORA PRA).docx Yes Yes Fillable Fileable
Form and Instruction CMS-10398 #54 EVV Good Faith Effort Request Form (Personal Care Services) GFE-PCS-Template3 (rev OSORA PRA).docx Yes Yes Fillable Fileable

Health Health Care Services

 

54 0
   
State, Local, and Tribal Governments
 
   100 %

  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 99 0 99 0 0 0
Annual IC Time Burden (Hours) 792 0 792 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
GenIC #54 - Supporting Statement 54 - Supporting Statement (version 2).docx 10/22/2018
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.