Information Collection

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

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 #54 GenIC #54 - Electronic Visit Verification (EVV) Good Faith Effort Exemption Requests	Form and Instruction
CMS-10398 #54 EVV Good Faith Effort Request Form (Home Health Care Ser 54 - EVV Good Faith Effort Exemption Requests GFE-HHCS-Template3 (rev OSORA PRA).docx	Form and Instruction
CMS-10398 #54 EVV Good Faith Effort Request Form (Personal Care Servic GFE-PCS-Template3 (rev OSORA PRA).docx	Form and Instruction
54 - Supporting Statement (version 2).docx GenIC #54 - Supporting Statement	IC Document

IC Title:

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

Agency IC Tracking Number:

CMCS

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

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-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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	99	99
Annual IC Time Burden (Hours)	792	792
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.