Home Office Cost Statement and Supporting Statement in Regulation in 42 CFR 413.17 and 413.20

ICR 199903-0938-001

OMB: 0938-0202

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0202 199903-0938-001
Historical Active 199605-0938-004
HHS/CMS
Home Office Cost Statement and Supporting Statement in Regulation in 42 CFR 413.17 and 413.20
Extension without change of a currently approved collection   No
Regular
Approved without change 05/03/1999
Retrieve Notice of Action (NOA) 03/05/1999
  Inventory as of this Action Requested Previously Approved
06/30/2002 06/30/2002 07/31/1999
1,231 0 1,231
573,646 0 573,646
0 0 0

Medicare law permits components of chain organizations to be reimbursed for certain cost incurred by the home offices of the chain. The home office cost statement is required by the fiscal intermediary to verify home office cost claimed by the components.

None
None


No

1
IC Title Form No. Form Name
Home Office Cost Statement and Supporting Statement in Regulation in 42 CFR 413.17 and 413.20 HCFA-287

  Total Approved 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 1,231 1,231 0 0 0 0
Annual Time Burden (Hours) 573,646 573,646 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
03/05/1999


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