View Information Collection (IC)

View Information Collection (IC)

Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument and Supporting Regulations in 42 CFR 488.26 and 442.30
 
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 CMS-1515A Home Health Functional Assessment Instrument Module A CMS-1515A.pdf No No Paper Only
Form CMS-1515B Home Health Functional Assessment Instrument: Module B CMS-1515B.pdf No No Paper Only
Form CMS-1515C Home Health Functional Assessment: Module C: Home Visit CMS-1515C.pdf No No Paper Only
Form CMS-1515D Home Health Functional Assessment Patient Function and Care Summary: Module D CMS-1515D.pdf No No Paper Only
Form CMS-1515E Home Health Function and Care Summary: Module D CMS-1515E.pdf No No Paper Only
Form CMS-1515F Calendar Worksheet - Prescribed Visits CMS-1515F.pdf No No Paper Only
Form CMS-1572 Home Health Agency Survey and Deficiencies Report 508CMS-1572.pdf No No Paper Only

Health Health Care Services

 

5,614 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 5,614 0 0 -3,131 0 8,745
Annual IC Time Burden (Hours) 9,825 0 0 5,452 0 4,373
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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