Information Collection

Medicare - Home Health Agency - Request For Certification In The Medicare/medicaid Program And The Home Health Survey Report Form

IC 113505 under ICR 198605-0938-006 · OMB 0938-0355.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0355 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	MEDICARE - HOME HEALTH AGENCY - REQUEST FOR CERTIFICATION IN THE MEDICARE/MEDICAID PROGRAM AND THE HOME HEALTH SURVEY REPORT FORM	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-1515				No	No
Form	HCFA-1572				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 53	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,180	912	2,268
Annual IC Time Burden (Hours)	5,565	1,596	3,969
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.