Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Trial Year and Routine Audits Modified 35 21000 0 Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Form CMS-10630 Appeals Impact Analysis Template
Form CMS-10630 Appeals Impact Analysis Template
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Form CMS-10630 Summary of any pre-audit issues
Form CMS-10630 PACE Supplemental Questionnaire
Form and Instruction CMS-10630 PACE Audit Process and Data Request Protocol
Form CMS-10630 Onsite Audit
Form and Instruction CMS-10630 Audit Survey
Form CMS-10630 Service Delivery Request and Appeals Impact Analysis Template
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Form CMS-10630 Grievances Impact Analysis Template
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Form CMS-10630 Personnel Impact Analysis Template
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Form CMS-10630 Root Cause Analysis Template
Form CMS-10630 Service Delivery Request Impact Analysis Template
Form CMS-10630 Service Delivery Request Impact Analysis Template
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Total burden requested under this ICR: 35 21000 0  
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