Home Health Agency Survey and Deficiencies Report and Supporting Regulations (CMS-1572)

OMB 0938-0355

In order to participate in the Medicare program as a Home Health Agency (HHA) provider, the HHA must meet Federal standards. The survey forms summarize data relative to provider characteristics, the patient population, and special needs of the patient populations. These forms are used to record information about patients’ health and provider compliance with requirements and report information to the Federal Government.

The latest form for Home Health Agency Survey and Deficiencies Report and Supporting Regulations (CMS-1572) expires 2021-01-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-1572 Home Health Agency Survey and Deficiencies Report Form and Instruction
CMS-1572 Supporting Statement A. 01.26.23.docx Supporting Statement A
Home Health Agency Survey and Deficiencies Report Form and Instruction

All Historical Document Collections

202301-0938-012 Approved without change	Revision of a currently approved collection	2023-01-31
202102-0938-001 Approved with change	Reinstatement with change of a previously approved collection	2021-02-04
201706-0938-001 Approved with change	Reinstatement without change of a previously approved collection	2017-06-15
201309-0938-014 Approved without change	Reinstatement with change of a previously approved collection	2013-09-13
201001-0938-008 Approved without change	Extension without change of a currently approved collection	2010-01-27
200611-0938-013 Approved without change	Extension without change of a currently approved collection	2006-11-22
200309-0938-004 Approved without change	Extension without change of a currently approved collection	2003-09-26
200201-0938-001 Approved without change	Extension without change of a currently approved collection	2002-01-04
199812-0938-003 Approved without change	Revision of a currently approved collection	1998-12-08
199602-0938-001 Approved without change	Reinstatement without change of a previously approved collection	1996-02-01
199403-0938-004 Approved without change	Reinstatement with change of a previously approved collection	1994-03-17
199204-0938-005 Approved without change	Revision of a currently approved collection	1992-04-17
199006-0938-004 Approved without change	Revision of a currently approved collection	1990-06-13
198908-0938-011 Approved without change	Revision of a currently approved collection	1989-08-28
198903-0938-004 Approved without change	Revision of a currently approved collection	1989-03-13
198605-0938-006 Approved without change	Revision of a currently approved collection	1986-05-06
198405-0938-007 Approved without change	New collection (Request for a new OMB Control Number)	1984-05-17