Information Collection

The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376

IC 7924 under ICR 200709-0938-010 · OMB 0938-0270.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0270 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-379 The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376	Form
CMS-379 Instructions ( Attachment #4).pdf	Instruction
CMS-379 Financial Statement of Debtor CMS-379.pdf	Form

IC Title:

The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 405.376(g) 32 CFR 901.8(a) 32 CFR 902.2(g)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-379	Financial Statement of Debtor	CMS-379.pdf		Yes	Yes	Paper Only
Instruction			CMS-379 Instructions ( Attachment #4).pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.