Information Collection

Hospice Cost Report and Supporting Regulations in 42 CFR 413.20 and 413.24

IC 8476 under ICR 202106-0938-004 · OMB 0938-0758.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0758 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
R4P243i Hospice Facility Cost Report.pdf	Instruction
R4P243i Hospice Facility Cost Report.pdf	Instruction
CMS-1984-14 Hospice Facility Cost Report R4P243f Form CMS-1984-14.pdf	Form
CMS-1984-14 Hospice Facility Cost Report R4P243f Form CMS-1984-14.pdf	Form

IC Title:

Hospice Cost Report and Supporting Regulations in 42 CFR 413.20 and 413.24

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 413.20 42 CFR 413.24

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
Instruction			R4P243i Hospice Facility Cost Report.pdf		No		Printable Only
Form	CMS-1984-14	Hospice Facility Cost Report	R4P243f Form CMS-1984-14.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,379

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

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	4,379	834	3,545
Annual IC Time Burden (Hours)	823,252	156,792	666,460
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.