OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Home Health Agency Survey and Deficiencies Report and Supporting Regulations (CMS-1572)

OMB 0938-0355 · HHS/CMS.

OMB 0938-0355

In order to participate in the Medicare program as a Home Health Agency (HHA) provider, the HHA must meet Federal standards. The survey forms summarize data relative to provider characteristics, the patient population, and special needs of the patient populations. These forms are used to record information about patients’ health and provider compliance with requirements and report information to the Federal Government.

The latest form for Home Health Agency Survey and Deficiencies Report and Supporting Regulations (CMS-1572) expires 2026-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material
Document
Name
Form and Instruction
Supporting Statement A
All Historical Document Collections
Approved without change
 Revision of a currently approved collection 2023-01-31
Approved with change
 Reinstatement with change of a previously approved collection 2021-02-04
Approved with change
 Reinstatement without change of a previously approved collection 2017-06-15
Approved without change
 Reinstatement with change of a previously approved collection 2013-09-13
Approved without change
 Extension without change of a currently approved collection 2010-01-27
Approved without change
 Extension without change of a currently approved collection 2006-11-22
Approved without change
 Extension without change of a currently approved collection 2003-09-26
Approved without change
 Extension without change of a currently approved collection 2002-01-04
Approved without change
 Revision of a currently approved collection 1998-12-08
Approved without change
 Reinstatement without change of a previously approved collection 1996-02-01
Approved without change
 Reinstatement with change of a previously approved collection 1994-03-17
Approved without change
 Revision of a currently approved collection 1992-04-17
Approved without change
 Revision of a currently approved collection 1990-06-13
Approved without change
 Revision of a currently approved collection 1989-08-28
Approved without change
 Revision of a currently approved collection 1989-03-13
Approved without change
 Revision of a currently approved collection 1986-05-06
Approved without change
 New collection (Request for a new OMB Control Number) 1984-05-17