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OMB Control No: 0938-0313	ICR Reference No: 202508-0938-024
Status: Received in OIRA	Previous ICR Reference No: 202106-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Hospice Request for Certification and Supporting Regulations (CMS-417)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 09/03/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	3,418	0
Time Burden (Hours)	2,564	0
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,418	1,359	2,059
Annual Time Burden (Hours)	2,564	1,020	1,544
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The total annual number of responses for both the CMS-417 forms has been increased from 2,059 in the previous PRA package to 3,418 in the current PRA package. This is an increase of 1,359 responses. The total annual combined time burden for the CMS-417 forms has increased from 1,544 hours in the previous PRA package to 2,564 hours in the current PRA package. This is an increase of 1,020 hours. The total annual combined cost burden for the CMS-417 forms has increased from $170,982 in the previous PRA package to $315,526 in the current PRA package. This is an increase of $144,544.

Annual Cost to Federal Government: $66,651

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Denise King 410 786-1013 Denise.King@cms.hhs.gov