Acute Hospital Care at Home

Submissions of 1135 Waiver Request Automated Process (CMS-10752)

OMB: 0938-1384

IC ID: 245795

Information Collection (IC) Details

View Information Collection (IC)

Acute Hospital Care at Home
No Modified
Required to Obtain or Retain Benefits

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10752 Acute Hospital at Home CMS 10752 NEW (AHCAH)_PRA Revision 022924.pdf Yes Yes Fillable Fileable

Health Health Care Services


351 0
Private Sector Businesses or other for-profits
   100 %

  Requested 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 351 0 61 0 0 290
Annual IC Time Burden (Hours) 5,217 0 3,318 0 0 1,899
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Tracked Changes - Acute Hospital at Home CMS 10752 Mock-Up (AHCAH)_PRA Revision.pdf 05/28/2024
Crosswalk - AHCAH CMS 10752 Crosswalk (AHCAH).pdf 05/28/2024
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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