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Federal forms, ICRs, and supporting documents

OMB control number

Hospice Survey and Deficiencies Report Form (CMS-643)

OMB 0938-0379 · HHS/CMS.

OMB 0938-0379

In order to participate in the Medicare program, a hospice must meet certain Federal health and safety conditions of participation. This form will be used by State surveyors to record data about a hospice's compliance with these conditions of participation in order to initiate the certification or recertification process.

The latest form for Hospice Survey and Deficiencies Report Form (CMS-643) expires 2026-05-31 and is listed under ICR 202212-0938-011.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CMS-643 Hospice Survey and Deficiencies ReportForm
Supporting Statement for CMS-643 (clean 3-30-26).docxSupporting Statement A
Hospice Survey and Deficiencies Report Form (CMS-643) Form

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202607-0938-007 Reinstatement with change of a previously approved collection 2026-07-21
202212-0938-011 Reinstatement with change of a previously approved collection 2022-12-27 Approved without change
201907-0938-005 Reinstatement without change of a previously approved collection 2019-08-13 Approved without change
201509-0938-007 Extension without change of a currently approved collection 2015-09-10 Approved with change
201207-0938-003 Extension without change of a currently approved collection 2012-07-18 Approved without change
200906-0938-005 Extension without change of a currently approved collection 2009-06-11 Approved with change
200604-0938-010 Extension without change of a currently approved collection 2006-04-26 Approved with change
200307-0938-010 Extension without change of a currently approved collection 2003-07-30 Approved with change
200006-0938-007 Extension without change of a currently approved collection 2000-06-14 Approved without change
199704-0938-001 Revision of a currently approved collection 1997-04-08 Approved without change
199403-0938-003 Reinstatement with change of a previously approved collection 1994-03-16 Approved without change
198909-0938-004 Revision of a currently approved collection 1989-09-12 Approved without change
198808-0938-002 Revision of a currently approved collection 1988-08-10 Approved without change
198707-0938-007 Revision of a currently approved collection 1987-07-28 Approved without change
198408-0938-004 New collection (Request for a new OMB Control Number) 1984-08-06 Approved without change