Hospice Survey and Deficiencies Report Form (CMS-643)

Hospice Survey and Deficiencies Report Form (CMS-643)

OMB: 0938-0379

IC ID: 8022

Information Collection (IC) Details

View Information Collection (IC)

Hospice Survey and Deficiencies Report Form (CMS-643)
 
No Modified
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-643 Hospice Survey and Deficiencies Report CMS-643.pdf Yes No Fillable Printable

Health Health Care Services

 

4,801 0
   
State, Local, and Tribal Governments
 
   0 %

  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 1,600 0 0 275 1,325 0
Annual IC Time Burden (Hours) 1,600 0 0 275 1,325 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
response to comments CMS-643 Response_to_Public_Comments.doc 07/29/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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