Independent Renal Dialysis Facility Cost Report and Supporting Regulations 42 CFR 413.20 and 42 CFR 413.24

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0236 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-265-94 Independent Renal Dialysis Facility Cost Report and Supporting Regulations 42 CFR 413.20 and 42 CFR 413.24 Form and Instruction
CMS-265-94 pr2_3400_to_3413.doc Instruction
CMS-265-94 pr2_3495_to_3495.doc Instruction
CMS-265-94 Independent Renal Dialysis Facility Cost Report CMS-265-94 pr2_34_toc.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Independent Renal Dialysis Facility Cost Report and Supporting Regulations 42 CFR 413.20 and 42 CFR 413.24	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 413.20 42 CFR 413.24

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-265-94	Independent Renal Dialysis Facility Cost Report	CMS-265-94 pr2_34_toc.doc	Yes	Yes	Paper Only
Instruction			CMS-265-94 pr2_3400_to_3413.doc	Yes	Yes	Paper Only
Instruction			CMS-265-94 pr2_3495_to_3495.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,885	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4,885	1,293	3,592
Annual IC Time Burden (Hours)	957,460	253,428	704,032
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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