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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 203679 under ICR 202409-0938-004 · OMB 0938-1153.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10390 Hospice Item Set - Descriptions HOPE v1.00_All Item_508c.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10390 Hospice Item Set - Admissions HOPE v1.00_Admission_508c.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10390 Hospice Item Set - Discharge HOPE v1.00_Discharge_508c.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10390 HOPE Update Visit HOPE v1.00_HOPE Update Visit_508c.pdf Yes Yes Fillable Fileable

Health Health Care Services

Hospice Item Set (HIS) System  79 FR 19341

5,640 4,850
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 2,763,850 0 0 0 0 2,763,850
Annual IC Time Burden (Hours) 1,323,883 0 0 0 0 1,323,883
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.