Information Collection

Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-05)

IC 7881 under ICR 200804-0938-005 · OMB 0938-0202.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0202 can be found here:

Documents and Forms

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 413.17 42 CFR 413.20

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Manual	287-05E.xls	Yes	Yes	Paper Only
Other-Manual	287-05F.xls	Yes	Yes	Paper Only
Other-Manual	287-05G.xls	Yes	Yes	Paper Only
Other-Manual	287-05I.xls	Yes	Yes	Paper Only
Other-Manual	287-05J.xls	Yes	Yes	Paper Only
Other-Manual	CMS-287 R1P239.doc	Yes	Yes	Paper Only
Other-Manual	287-05A.xls	Yes	Yes	Paper Only
Other-Manual	287-05B.xls	Yes	Yes	Paper Only
Other-Manual	287-05C.xls	Yes	Yes	Paper Only
Other-Manual	287-05D.xls	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,345

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,345	114	1,231
Annual IC Time Burden (Hours)	626,770	53,124	573,646
Annual IC Cost Burden (Dollars)	0	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.