Information Collection

Participation Exemption Request (PER) Form

IC 210204 under ICR 202512-0938-004 · OMB 0938-1066.

Documents and Forms

Document Name Document Type
Form CMS-10275 Participation Exemption Request (PER) Form Form and Instruction
Form CMS-10275 11. CMS-10275. Attachment F_HHCAHPS Participation Exemption Request Form 2026 APU (final rule) Participation Exemption Request (PER) Form Form and Instruction
CMS-10275 11. CMS-10275. Attachment F_HHCAHPS Participation Exempt 11. CMS-10275. Attachment F_HHCAHPS Participation Exemption Request Form 2026 APU (final rule).pdf Form and Instruction
CMS-10275 11. CMS-10275. Attachment F_HHCAHPS Participation Exempt 11. CMS-10275. Attachment F_HHCAHPS Participation Exemption Request Form 2026 APU (final rule).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Participation Exemption Request (PER) Form	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10275	11. CMS-10275. Attachment F_HHCAHPS Participation Exemption Request Form 2026 APU (final rule)	11. CMS-10275. Attachment F_HHCAHPS Participation Exemption Request Form 2026 APU (final rule).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 940	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	940	240	700
Annual IC Time Burden (Hours)	310	79	231
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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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