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Agenda
Reg Review
ICR
Information Collection List
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument and Supporting Regulations in 42 CFR 488.26 and 442.30
Modified
5614
9825
0
Form
CMS-1515A
Home Health Functional Assessment Instrument Module A
Form
CMS-1515B
Home Health Functional Assessment Instrument: Module B
Form
CMS-1515C
Home Health Functional Assessment: Module C: Home Visit
Form
CMS-1515D
Home Health Functional Assessment Patient Function and Care Summary: Module D
Form
CMS-1515E
Home Health Function and Care Summary: Module D
Form
CMS-1515F
Calendar Worksheet - Prescribed Visits
Form
CMS-1572
Home Health Agency Survey and Deficiencies Report
Total burden requested under this ICR:
5614
9825
0
To view an IC, click on IC Title