View Information Collection (IC)

View Information Collection (IC)

IC Title:	Hospice Cost Report and Supporting Regulations in 42 CFR 413.20 and 413.24	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 413.24 42 CFR 413.20

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			R1p243 [rev 11-22-2013].doc		Yes	No	Fillable Printable
Form	CMS-1984-14	Hospice Cost Report	R1p243f.pdf		Yes	Yes	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: 2,751	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	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	2,751	0	0	448	0	2,303
Annual IC Time Burden (Hours)	517,188	0	896	110,964	0	405,328
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	CMS-1984-14-Revisions Crosswalk from old to new.doc	11/22/2013

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