View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

Trial Year and Routine Audits
 
No Modified
 
Mandatory
 
42 CFR 460.190 42 CFR 460.192

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template AlertIDT1P14.pdf Yes Yes Fillable Fileable
Form CMS-10630 Appeals Impact Analysis Template AppealExt1P71.pdf Yes Yes Fillable Fileable
Form CMS-10630 Appeals Impact Analysis Template Appeals1P651P661P681P73.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template Assessments1P491P501P82.pdf Yes Yes Fillable Fileable
Form CMS-10630 Summary of any pre-audit issues AttachmentIIIPre-AuditIssueSummary.pdf Yes Yes Fillable Fileable
Form CMS-10630 PACE Supplemental Questionnaire AttachmentIIPACESupplementalQuestions.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10630 PACE Audit Process and Data Request Protocol AttachmentIPACEAuditProcessDataRequest.pdf Yes Yes Fillable Fileable
Form CMS-10630 Onsite Audit AttachmentIVOnsiteObsPartList.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10630 Audit Survey AttachmentVAuditSurvey.pdf Yes Yes Fillable Fileable
Form CMS-10630 Service Delivery Request and Appeals Impact Analysis Template Effectuation1P021P111P30.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template EmergencyCare1P07.pdf Yes Yes Fillable Fileable
Form CMS-10630 Grievances Impact Analysis Template Grievances1P311P751P77.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template HomeCare1P02.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template MedErrors1P02.pdf Yes Yes Fillable Fileable
Form CMS-10630 Personnel Impact Analysis Template Personnel.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template ProvisionofServices1P021P81.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template Restraints1P09.pdf Yes Yes Fillable Fileable
Form CMS-10630 Root Cause Analysis Template RootCauseTemplate.pdf Yes Yes Fillable Fileable
Form CMS-10630 Service Delivery Request Impact Analysis Template SDRIdentification1P76.pdf Yes Yes Fillable Fileable
Form CMS-10630 Service Delivery Request Impact Analysis Template SDRs1P601P611P85.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template SrvcRestrict1P90.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template WoundCare1P02.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

131 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 35 0 -37 0 0 72
Annual IC Time Burden (Hours) 21,000 0 3,720 0 0 17,280
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.