Information Collection

Outpatient Physical Therapy Speech Pathology Survey Report and Supporting Regulation in 42 CFR 485.701-485.729

IC 7822 under ICR 202108-0938-005 · OMB 0938-0065.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1856 Outpatient Physical Therapy Speech Pathology Survey Report and Supporting Regulation in 42 CFR 485.701-485.729	Form and Instruction
Form CMS-1856 Request for Certification in the Medicare and/or Medicaid Program Outpatient Physical Therapy Speech Pathology Survey Report and Supporting Regulation in 42 CFR 485.701-485.729	Form and Instruction
CMS-1856 Request for Certification in the Medicare and/or Medicai Form CMS-1856 (05-11-21)_ 508 compliant.pdf	Form and Instruction
CMS-1856 Request for Certification in the Medicare and/or Medicai Form CMS-1856 (05-11-21)_ 508 compliant.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 485.701-485.729

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-1856				No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 195

Number of Respondents for Small Entity: 170

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	195	-155	350
Annual IC Time Burden (Hours)	49	-39	88
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.

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