Information Collection

Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form

IC 203679 under ICR 202407-0938-018 · OMB 0938-1153.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1153 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10390 Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form	Form and Instruction
Form CMS-10390 Hospice Item Set - Descriptions Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form	Form and Instruction
Form CMS-10390 Hospice Item Set - Admissions Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form	Form and Instruction
Form CMS-10390 Hospice Item Set - Discharge Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form	Form and Instruction
HIS_UserManualVersion_3.0_February2021.pdf	Instruction
HIS_UserManualVersion_3.0_February2021.pdf	Instruction
CMS-10390 Hospice Item Set - Descriptions CMS-10390 - HQRP Hospice Item Set- Item Descriptions.pdf	Form and Instruction
CMS-10390 Hospice Item Set - Descriptions CMS-10390 - HQRP Hospice Item Set- Item Descriptions.pdf	Form and Instruction
CMS-10390 Hospice Item Set - Admissions CMS-10390 - HQRP HIS Admissions_508c_8-7-23.pdf	Form and Instruction
CMS-10390 Hospice Item Set - Admissions CMS-10390 - HQRP HIS Admissions_508c_8-7-23.pdf	Form and Instruction
CMS-10390 Hospice Item Set - Discharge CMS-10390 - HQRP-HIS-v3000-Discharge_508c_8-7-23.pdf	Form and Instruction
CMS-10390 Hospice Item Set - Discharge CMS-10390 - HQRP-HIS-v3000-Discharge_508c_8-7-23.pdf	Form and Instruction

IC Title:

Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10390	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Hospice Item Set (HIS) System

FR Citation: 79 FR 19341

Number of Respondents: 5,640

Number of Respondents for Small Entity: 4,850

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	2,763,850	2,763,850
Annual IC Time Burden (Hours)	1,323,883	1,323,883
Annual IC Cost Burden (Dollars)	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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].