Information Collection

Acute Hospital Care at Home

IC 245795 under ICR 202606-0938-015 · OMB 0938-1384.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10752 Acute Hospital at Home Acute Hospital Care at Home	Form and Instruction
Form CMS-10752 AHCAH Data Measures form Acute Hospital Care at Home	Form and Instruction
Form CMS-10752 AHCAH waiver 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 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 Crosswalk (AHCAH).pdf Crosswalk - AHCAH	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

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-10752	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10752	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10752	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 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-496	496
Annual IC Time Burden (Hours)	-1,625	1,625
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk - AHCAH		05/28/2024

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

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