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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX (Expires XX/XX/XXXX). This
is a voluntary information collection. The time required to complete this information collection is estimated to average 5 minutes per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance O cer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents
containing sensitive information to the PRA Reports Clearance O ce. Please note that any correspondence not pertaining to the
information collection burden approved under the associated OMB control number listed on this form will not be reviewed,
forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Gladys
Olomukoro at Gladys.Olomukoro@cms.hhs.gov
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Category: Reporting
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Supervisor
Category: Patient Assessment
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Category: Survey & Certification - Providers
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Category: Survey & Certification - Surveys
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Category: Survey & Certification - Intakes
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Category: Survey & Certification - Enforcements
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Reporting
Patient Assessment
Survey & Certification - Providers
Survey & Certification - Surveys
Survey & Certification - Intakes
Survey & Certification -Enforcements
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| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |