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OMB Control No: 0938-0379	ICR Reference No: 202607-0938-007
Status: Received in OIRA	Previous ICR Reference No: 202212-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Hospice Survey and Deficiencies Report Form (CMS-643)
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: 07/21/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	2,343	0
Time Burden (Hours)	1,172	0
Cost Burden (Dollars)	0	0

Abstract: In order to participate in the Medicare program, a hospice must meet certain Federal health and safety conditions of participation. This form will be used by State surveyors to record data about a hospice's compliance with these conditions of participation in order to initiate the certification or recertification process.

Authorizing Statute(s): US Code: 42 USC 442.30 Name of Law: Agreement as evidence of Certification
US Code: 42 USC 488.26 Name of Law: Determining Compliance

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 23271	04/30/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 43642	07/16/2026
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Hospice Survey and Deficiencies Report Form (CMS-643)	CMS-643

ICR Summary of Burden

	Total Request	Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses	2,343	292	2,051
Annual Time Burden (Hours)	1,172	-48,052	49,224
Annual Cost Burden (Dollars)	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Tthe number of annual surveys has increased from 2,051 to 2,343 which is 292 based on hospice growth. The burden hours decreased significantly from 49,224 hours to 1,172 hours. The annual burden has been recalculated to reflect 30 minutes for completion of the hospice to gather the information for the surveyors to complete the CMS-643 form. We note the significant decrease in the burden hours, and cost is due to our reevaluation of the form and the survey entities which incur the burden. We have also revised the form to reduce duplication of information collected and also adjusted the burden calculations to reflect the time that the hospice will take to gather documentation to support the surveyor in completing this form as part of the standard survey process (refer to Section 14). In the prior cost analysis, calculated the burden hours and cost of surveyors collecting and reporting this information. CMS allocates funding to each state for the reasonable costs of surveying to certify compliance or non-compliance of providers and suppliers as specified in the 1864 Agreement, therefore calculation of surveyor costs was unnecessary in the prior form package. Completing the CMS-643 form imposes minimal cost burden to hospice providers as the documentation provided to the State Survey Agencies and Accrediting Organizations (AOs) for deemed hospices surveyors is part of documentation the hospice needs to provide to demonstrate compliance to participate in the Medicare program.

Annual Cost to Federal Government: $0

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

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