Information Collection

Inpatient Psychiatric Facility-Patient (IPF-PAI) Assessment

IC 279851 under ICR 202607-0938-018 · OMB 0938-1496.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10954 IPF-PAI_Admission Inpatient Psychiatric Facility-Patient (IPF-PAI) Assessment	Form and Instruction
Form CMS-10954 IPF-PAI_Discharge Inpatient Psychiatric Facility-Patient (IPF-PAI) Assessment	Form and Instruction
CMS-10954 IPF-PAI_Admission CMS-10954_IPF-PAI_v1.0_Admission.pdf	Form and Instruction
CMS-10954 IPF-PAI_Discharge CMS-10954_IPF-PAI_v1.0_Discharge.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

CCSQ

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-10954				Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10954				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Beneficiary Database (09-70-0536)

FR Citation: 71 FR 70396

Number of Respondents: 1,564

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: 100 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	2,098,888	2,098,888
Annual IC Time Burden (Hours)	419,778	419,778
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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