Information Collection

HOPE and HUV Timepoint

IC 269622 under ICR 202409-0938-004 · OMB 0938-1153.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10390 HOPE and HUV Timepoint	Form
Form CMS-10390 HOPE v1.00_All Item_Final_022625 HOPE and HUV Timepoint	Form and Instruction
CMS-10390 Hospice Outcome and Patient Evaluation HOPE v1.00_All Item_508c.pdf	Form
CMS-10390 HOPE v1.00_All Item_Final_022625 HOPE v1.00_All Item_Final_022625.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,640

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	2,763,600	2,763,600
Annual IC Time Burden (Hours)	2,487,465	2,487,465
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.

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