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Home Health Agency Survey and Deficiencies Report

IC 7990 under ICR 202301-0938-012 · OMB 0938-0355.

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Home Health Agency Survey and Deficiencies Report
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 488.26 42 CFR 442.30

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-1572 Home Health Agency And Deficiences Report CMS 1572. 12.19.22.docx No   Fillable Fileable
Form and Instruction CMS-1572 Home Health Agency and Deficiencies Report CMS 1572. 12.21.22.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

3,833 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 3,833 0 0 0 0 3,833
Annual IC Time Burden (Hours) 1,917 0 0 0 0 1,917
Annual IC Cost Burden (Dollars) 142,778 0 0 0 0 142,778

Title Document Date Uploaded
Crosswalk Change Crosswalk for CMS-1572. 11.01.22.docx 01/27/2023
Compare version of CMS-1572 CMS.1572 form COMPARE VERSION. 01.26.23.docx 01/27/2023
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.