Existing Hospices

(CMS-417) Hospice Request for Certification and Supporting Regulations

Documents and Forms

Document Name Document Type
Form CMS-417 Existing Hospices Form and Instruction
CMS-417 Hospice Request for Certification in the Medicare Progra CMS-417. 03.01.21.pdf Form and Instruction
CMS-417 Hospice Request for Certification in the Medicare Progra CMS-417. 03.01.21.pdf Form and Instruction
Change Crosswalk for CMS-417. 03.01.21.docx Crosswalk IC Document
Change Crosswalk for CMS-417. 03.01.21.docx Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Existing Hospices	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 489.11-489.20

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-417	Hospice Request for Certification in the Medicare Program	CMS-417. 03.01.21.pdf		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,748	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,748	897	851
Annual IC Time Burden (Hours)	1,311	1,098	213
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Change Crosswalk for CMS-417. 03.01.21.docx	06/21/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.