Items 1 to 6: facility and administrator
Name of facility, provider number, street address, telephone, name of administrator and the administrator's qualification: RN, physician, undergrad degree or other.
CMS-1572
HHA SURVEY REPORT
- Agency
- CMS
- Revision
- 2022-07-01
- Fillable fields
- 61
- Pages
- 3
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-1572: Home Health Agency Survey Report
Form CMS-1572 is the Home Health Agency Survey Report from the Centers for Medicare & Medicaid Services (CMS), part of the U.S. Department of Health and Human Services. The CMS forms page lists it as the HHA Survey Report. It has two parts: Part 1 is to be completed by facility staff, and Part 2 is to be completed by the surveyor.
Part 1 asks for the home health agency's name, provider number, address and administrator, its type of control, any change of ownership since the last survey, any co-located hospice, its branch locations, how each type of service is provided and staffing in full-time equivalents. Part 2 records the type of survey and survey data such as the total number of home visits.
The form does not print a mailing address for the completed report. Its disclaimer points questions about where to submit documents to [email protected]. Each page shows OMB No. 0938-0355 with an approval expiration date of 06/30/2026. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-1572
Items 7 and 8: control and ownership
Type of control (proprietary, government operated or non-profit) and whether there has been a change of ownership of the facility since the last survey.
Items 9 and 10: hospice and branches
Whether the agency is co-located with a separately Medicare-certified hospice, and a table of branch locations with branch number, branch name and mailing address.
Item 11: services provided
For ten services, from skilled nursing and therapy to home health aide, pharmaceutical, infusion, laboratory and outpatient therapy services, whether each is provided by HHA staff, under arrangement or a combination.
Item 12: staffing
Full-time equivalents, not hours, for direct hire staff and staff under arrangement in ten job types from registered nurses to home health aides, plus the name and title of the person completing the form and the date.
Part 2: survey
Item 13 records the type of survey, initial or recertification, coded 1 to 6 for standard, partial extended, extended and combinations. Item 14 records the total number of home visits and the number of records reviewed with no home visits.
How to fill out Form CMS-1572
- 1
Identify the agency
Facility staff enter the facility name, provider number, street address, telephone, administrator and the administrator qualification code.
- 2
Answer the control and ownership questions
Enter the type of control code and answer yes or no on a change of ownership since the last survey and on co-location with a separately Medicare-certified hospice.
- 3
List branch locations
If the agency operates branches, give how many and each branch's official name and full mailing address. The form says to attach a separate page and check the box if more space is needed.
- 4
Code each service
For each service in item 11, enter 1 for HHA staff, 2 for under arrangement or 3 for a combination.
- 5
Report staffing in FTEs
List full-time equivalents, not hours, for direct hire staff and staff under arrangement, then add the name and title of the person completing the form and the date.
- 6
Surveyor completes Part 2
The surveyor records the type of survey and the survey data in items 13 and 14.
Why fill Form CMS-1572 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
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- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Submitting the report and what it says
Where it goes
The form does not print a mailing address. Its disclaimer says questions or concerns about where to submit documents go to [email protected].
Not to the PRA office
The form says not to send applications, claims, payments, medical records or documents with sensitive information to the PRA Reports Clearance Office. That CMS address is for comments on the time estimate.
OMB approval
The form shows OMB No. 0938-0355 and an OMB approval expiration date of 06/30/2026. The CMS page lists the same expiration date.
Time to complete
The form estimates an average of 30 minutes per response, including reviewing instructions, searching data resources and gathering the data.
Related forms
CMS-2802C
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOME HEALTH AGENCY
34 fields, 1 page
CMS-2567
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
22 fields, 5 pages
CMS-1539
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
51 fields, 2 pages
CMS-855A
Medicare Enrollment Application - Institutional Providers
1,236 fields, 72 pages
CMS-807
Surveyor Notes Worksheet
11 fields, 2 pages
Who uses Form CMS-1572?
The form splits the work between the home health agency and the surveyor.
Official sources and the blank
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Questions about Form CMS-1572
Who fills out Form CMS-1572?
The form says Part 1 is to be completed by facility staff and Part 2 by the surveyor.
Are staffing numbers entered in hours?
No. Item 12 asks for full-time equivalents, not hours, for direct hire staff and for staff under arrangement.
What if the agency has more than four branches?
The branch table has four rows. The form says to attach a separate page and check the box if additional space is needed.
What do the service codes in item 11 mean?
The form uses 1 for HHA staff, 2 for under arrangement and 3 for a combination.
Where do I send Form CMS-1572?
The form does not print a mailing address. It says questions or concerns about where to submit documents go to [email protected].
What OMB number and date does the form show?
Each page shows OMB No. 0938-0355 and an OMB approval expiration date of 06/30/2026.