Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Trial Year and Routine Audits New 72 17280 0 Form and Instruction CMS-10630 PACE Audit Process and Data Request Protocol
Form CMS-10630 PACE Supplemental Questions
Form CMS-10630 Pre-Audit Issue Summary
Form CMS-10630 Service Delivery Impact Analysis Template
Form CMS-10630 Appeals Impact Analysis Template
Form CMS-10630 Grievances Impact Analysis Template
Form CMS-10630 Root Cause Analysis Template
Form CMS-10630 Clinical Appropriateness for Comprehensive Care Impact Analysis Template
Form CMS-10630 Clinical Appropriateness for Emergencies Impact Analysis Template
Form CMS-10630 Clinical Appropriateness for IDT Documentation Impact Analysis Template
Form CMS-10630 Clinical Appropriateness for Medical Record Documentation Impact Analysis Template
Form CMS-10630 Clinical Appropriateness for Restraints Impact Analysis Template
Form CMS-10630 Clinical Appropriateness for Care Planning Impact Analysis Template
Form CMS-10630 Clinical Appropriateness for Assessments Impact Analysis Template
Form CMS-10630 Clinical Appropriateness for Infections Impact Analysis Template
Form CMS-10630 Clinical Appropriateness for Providers Impact Analysis Template
Form CMS-10630 Clinical Appropriateness for Transportation Impact Analysis Template
Form CMS-10630 Personnel Impact Analysis Template
Total burden requested under this ICR: 72 17280 0  
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