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

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.