Information Collection

Provider Cost Report Reimbursement Questionnaire

IC 113390 under ICR 198510-0938-007 · OMB 0938-0301.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0301 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-339				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 18,012	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	18,012	1,049	1,463	15,500
Annual IC Time Burden (Hours)	396,264	36,024	50,240	310,000
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.