CMS Pub. 100-04, ch. 30, § 60.4

A. Notices and General Notice Requirements

The HHCCN and the general instructions for preparing the HHCCN are available for

download at the home health notice link found at

http://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html.

The notice is available in English and Spanish, and in PDF and Word formats. The

HHCCN is the Office of Management and Budget (OMB) approved standard notice for

use by Medicare HHAs to inform beneficiaries of changes in the POC when required by

the COPs for HHAs. HHAs must use the OMB approved standard notice. HHAs must

not add any customizations to the notice beyond what is permitted by the accompanying

HHCCN form instructions and the guidelines published in this section.

B. Choosing the Correct Language Version

HHAs should choose the appropriate version of the HHCCN based on the language the

beneficiary best understands. When a Spanish-language HHCCN is used, the HHA

should make insertions on the notice in Spanish. If this is impossible, the HHA must take

additional steps needed to assure beneficiary comprehension and document this on the

HHCCN.

If needed, HHAs must provide verbal assistance in other languages to assist beneficiaries

in understanding the document. HHAs should document any types of translation

assistance used in the “Additional Information” section of the notice.

C. Compliance with Paperwork Reduction Act of 1995

Consistent with the Paperwork Reduction Act of 1995, the valid OMB control number for

this information collection appearing on the HHCCN is 0938-1196. The estimated time

required to complete this information collection is 4 minutes for a single notice. This

includes the time to prepare the notice, review it with the beneficiary, and obtain the

beneficiary’s signature.

D. Effective Dates

HHCCNs are effective for HHA use per the OMB assigned date given at the bottom of

each notice unless CMS instructs HHAs otherwise. The routine approval is for 3-year

use. HHAs are expected to exclusively use the effective version of the HHCCN per CMS

directives.