Information Collection

Acute Hospital Care at Home

IC 245795 under ICR 202405-0938-028 · OMB 0938-1384.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1384 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10752 Acute Hospital Care at Home	Form and Instruction
CMS-10752 Acute Hospital at Home CMS 10752 NEW (AHCAH)_PRA Revision 022924.pdf	Form and Instruction
CMS-10752 Acute Hospital at Home CMS 10752 NEW (AHCAH)_PRA Revision 022924.pdf	Form and Instruction
CMS-10752 AHCAH Data Measures form AHCAH Data Measures form.pdf	Form and Instruction
CMS-10752 AHCAH waiver Acute Hospital Care at Home Waiver updated.pdf	Form and Instruction
CMS 10752 Mock-Up (AHCAH)_PRA Revision.pdf Tracked Changes - Acute Hospital at Home	IC Document
CMS 10752 Crosswalk (AHCAH).pdf Crosswalk - AHCAH	IC Document
CMS 10752 Crosswalk (AHCAH).pdf Crosswalk - AHCAH	IC Document

IC Title:

Acute Hospital Care at Home

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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
Form and Instruction	CMS-10752	AHCAH Data Measures form	AHCAH Data Measures form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10752	AHCAH waiver	Acute Hospital Care at Home Waiver updated.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 496

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	496	206	290
Annual IC Time Burden (Hours)	1,625	-274	1,899
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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.