HOPE All Items v1.01, PRA Disclosure Statement

PRA Disclosure Statement

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. HOPE is a patient assessment instrument that

intends to collect data during a hospice patient’s stay. Data collected using this instrument will be used to

measure the quality of care provided by a hospice provider. The valid OMB control number for this information

collection is 0938-1153. Submission of this data is required by Section 1814(i)(5) of the Social Security Act.

The time required to complete this data collection per item set is estimated to average 41 minutes for the

Admission, 22 minutes for the Hope Update Visit, and 9 minutes for the Discharge, including the time to

review instructions, search existing data resources, gather the data needed, and complete and review the data

collected. Submitted patient-level data will remain confidential and is protected from public dissemination in

accordance with the Privacy Act of 1974, as amended. 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 Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Please do not send applications, claims, payments, medical records or any documents containing sensitive

information to the PRA Reports Clearance Office. 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 Jermama Keys, National Coordinator, Hospice Quality Reporting Program Centers

for Medicare & Medicaid Services, at Jermama.Keys@cms.hhs.gov.