OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Hospice Request for Certification and Supporting Regulations (CMS-417)

OMB 0938-0313 · HHS/CMS.

OMB 0938-0313

The Hospice Request for Certification Form is the identification and screening form used to initiate the certification process and to determine if the provider has sufficient personnel to participate in the Medicare program.

The latest form for Hospice Request for Certification and Supporting Regulations (CMS-417) expires 2029-02-28 and is listed under ICR 202508-0938-024.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CMS-417 Hospice Request for Certification in the Medicare ProgramForm and Instruction
Form CMS-417 Existing HospicesForm and Instruction
Supporting Statement Part A. CMS-417. 08.13.25.docxSupporting Statement A
Existing Hospices Form and Instruction
Existing Hospices Form and Instruction
New Hospices Information collection

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202508-0938-024 Reinstatement with change of a previously approved collection 2025-09-03
202106-0938-010 Reinstatement with change of a previously approved collection 2021-06-22 Approved without change
201710-0938-010 Reinstatement without change of a previously approved collection 2017-10-30 Approved with change
201401-0938-017 Revision of a currently approved collection 2014-01-31 Approved without change
201012-0938-011 Extension without change of a currently approved collection 2010-12-16 Approved without change
200708-0938-007 Extension without change of a currently approved collection 2007-08-22 Approved without change
200405-0938-007 Extension without change of a currently approved collection 2004-05-17 Approved without change
200106-0938-011 Extension without change of a currently approved collection 2001-06-19 Approved without change
199805-0938-005 Extension without change of a currently approved collection 1998-05-21 Approved without change
199702-0938-011 No material or nonsubstantive change to a currently approved collection 1997-02-28 Approved with change
199508-0938-002 Reinstatement without change of a previously approved collection 1995-08-22 Approved without change
199505-0938-002 Reinstatement without change of a previously approved collection 1995-05-05 Improperly submitted
199107-0938-004 Revision of a currently approved collection 1991-07-15 Approved without change
198805-0938-003 Revision of a currently approved collection 1988-05-09 Approved without change
198505-0938-005 Revision of a currently approved collection 1985-05-07 Approved without change
198503-0938-032 No material or nonsubstantive change to a currently approved collection 1985-03-18 Approved with change
198409-0938-033 No material or nonsubstantive change to a currently approved collection 1984-09-28 Approved with change
198310-0938-031 New collection (Request for a new OMB Control Number) 1983-10-19 Approved without change

OMB Details

Existing Hospices

Federal Enterprise Architecture: Health - Health Care Services

Information collection instruments
FormNameElectronic accessType
Form CMS-417Hospice Request for Certification in the Medicare ProgramFillable FileableForm and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.