OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

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

OMB 0938-0355 · HHS/CMS.

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 2026-06-30 and is listed under ICR 202301-0938-012.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CMS-1572 Home Health Agency Survey and Deficiencies ReportForm and Instruction
CMS-1572 Supporting Statement A. 01.26.23.docxSupporting Statement A
Home Health Agency Survey and Deficiencies Report Form and Instruction

All Historical Document Collections

Historical document collections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