Hospice Request for Certification and Supporting Regulations (CMS-417)

Forms and Documents

Document Name	Status
Form CMS-417 Existing Hospices Form and Instruction	Modified
Supporting Statement Part A. CMS-417. 08.13.25.docx Supporting Statement A	2025-09-02

IC Document Collections

IC ID	Document Title	Status
7960	Existing Hospices Form and Instruction	Modified
247998	New Hospices	Modified

ICR Details

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

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Abstract: The Hospice Request for Certification Form is the identification and screening form used to initiate the certification process and to determine if the provider has sufficient personnel to participate in the Medicare program.

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Authorizing Statute(s): PL: Pub.L. 97 - 248 1861 Name of Law: Social Security Act
   US Code: 42 USC 418 Name of Law: Hospice Care
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 24803	06/12/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 42411	09/02/2025
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Existing Hospices	CMS-417	Hospice Request for Certification in the Medicare Program
New Hospices

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ICR Summary of Burden

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

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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

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/03/2025

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