Acute Hospital Care at Home

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.