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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
(Home Health Agencies) Survey of Access to Home Health Services for Medicare Beneficiaries
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-10429
(Home Health Agencies) Survey of Access to Home Health Services for Medicare Beneficiaries
HHSC_HHA Survey [rev 6-27-20012].pdf
No
No
Fillable Printable
Other-Cover Letter
HHSC_HHA cover letter 03292012_508.pdf
No
No
Printable Only
Other-Post Card
HHSC_HHA postcard text 04122012_508.pdf
No
No
Printable Only
Other-Letter
HHSC_HHA prenotice letter 03292012_508.pdf
No
No
Printable Only
Instruction
HHSC_Prompting script 03292012_508.pdf
No
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
600
Number of Respondents for Small Entity:
540
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
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
600
600
0
0
0
0
Annual IC Time Burden (Hours)
150
150
0
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.