Information Collection

Hospice Conditions of Participation 418.28(d) develop revocation form

IC 211883 under ICR 202604-0938-016 · OMB 0938-1067.

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IC Title:	Hospice Conditions of Participation 418.28(d) develop revocation form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 418.28(d)

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,460	Number of Respondents for Small Entity: 95

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	546	546
Annual IC Time Burden (Hours)	137	137
Annual IC Cost Burden (Dollars)	0	0

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