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Federal forms, ICRs, and supporting documents

Information Collection Request

MEDICARE - HOME HEALTH AGENCY - REQUEST FOR CERTIFICATION IN THE MEDICARE/MEDICAID PROGRAM AND THE HOME HEALTH SURVEY REPORT FORM

ICR 198903-0938-004 · OMB 0938-0355 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
113506 MEDICARE - HOME HEALTH AGENCY - REQUEST FOR CERTIFICATION IN THE MEDICARE/MEDICAID PROGRAM AND THE HOME HEALTH SURVEY REPORT FORM Form Migrated
ICR Details
0938-0355 198903-0938-004
Historical Active 198605-0938-006
HHS/CMS
MEDICARE - HOME HEALTH AGENCY - REQUEST FOR CERTIFICATION IN THE MEDICARE/MEDICAID PROGRAM AND THE HOME HEALTH SURVEY REPORT FORM
Revision of a currently approved collection   No
Regular
Approved without change 05/11/1989
Retrieve Notice of Action (NOA) 03/13/1989
Approved for use through 9/89 under the condition that the next submission incorporates resident rights and home health aide training and competency conditions as implemented by BERC-476-FC.
  Inventory as of this Action Requested Previously Approved
09/30/1989 09/30/1989 06/30/1989
3,180 0 3,180
5,565 0 5,565
0 0 0
IN ORDER TO PARTICIPATE IN THE MEDICARE/MEDICAID PROGRAM AS A HOME HEALTH AGENCY, PROVIDERS MUST MEET FEDERAL CONDITIONS OF PARTICIPATION THIS CERTIFICATION FORM IS NEEDED TO DETERMINE IF PROVIDERS MEET AT LEAST PRELIMINARY REQUIREMENTS. THE SURVEY FORM IS USED TO RECORD PROVIDERS COMPLIANCE WITH INDIVIDUAL CONDITIONS AND TO REPORT IT TO HCFA.
None
None
No
1
IC Title Form No. Form Name
MEDICARE - HOME HEALTH AGENCY - REQUEST FOR CERTIFICATION IN THE MEDICARE/MEDICAID PROGRAM AND THE HOME HEALTH SURVEY REPORT FORM HCFA-1515, HCFA-1572
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 3,180 3,180 0 0 0 0
Annual Time Burden (Hours) 5,565 5,565 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
03/13/1989