View Information Collection (IC)

View Information Collection (IC)

IC Title:	PLAN OF TREATMENT (POT) & HOME HEALTH CERTIFICATION FORM, HCFA-485 MEDICAL INFORMATION FORM (MIF), HCFA-486 ADDENDUM TO THE POT & MIF, HCFA-487, & INTERMEDIARY MED., HCFA-488	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-485,				No	No
Form	488				No	No
Form	486, 487,				No	No

Federal Enterprise Architecture Business Reference Module

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,320	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 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	1	0	0	-2,654,385	0	2,654,386
Annual IC Time Burden (Hours)	1	0	0	-1,216,598	0	1,216,599
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.