Information Collection

End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112

IC 8237 under ICR 201004-0938-006 · OMB 0938-0657.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0657 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-685 End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112 Form
CMS-685 Updated J 6 A Instructions with Disclosure statement CMS-685.FINAL Updated J 6 A Instructions with Disclosure statement.doc Instruction
CMS-685 CMS-685.FINAL J 6 E-NW 719 Semi Annual Cost Report with CMS-685.FINAL J 6 E-NW 719 Semi Annual Cost Report with SIMS_20060215.xls Form
CMS-685 CMS-685.FINAL J 6 D-NW 719 Semi Annual Voucher Version w CMS-685.FINAL J 6 D-NW 719 Semi Annual Voucher Version with NCC_20060215.xls Form
CMS-685 CMS-685.FINAL J 6 C-NW 719 Monthly Voucher Version with CMS-685.FINAL J 6 C-NW 719 Monthly Voucher Version with SIMS_20060215.xls Form
CMS-685 CMS-685.FINAL J 6 B-NW 719 Monthly Voucher Version with CMS-685.FINAL J 6 B-NW 719 Monthly Voucher Version with NCC_20060215.xls Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112	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 405.2110 42 CFR 405.2112

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-685	CMS-685.FINAL J 6 B-NW 719 Monthly Voucher Version with NCC	CMS-685.FINAL J 6 B-NW 719 Monthly Voucher Version with NCC_20060215.xls	Yes	Yes	Fillable Printable
Instruction	CMS-685	Updated J 6 A Instructions with Disclosure statement	CMS-685.FINAL Updated J 6 A Instructions with Disclosure statement.doc	Yes	Yes	Fillable Printable
Form	CMS-685	CMS-685.FINAL J 6 E-NW 719 Semi Annual Cost Report with SIMS	CMS-685.FINAL J 6 E-NW 719 Semi Annual Cost Report with SIMS_20060215.xls	Yes	Yes	Fillable Printable
Form	CMS-685	CMS-685.FINAL J 6 D-NW 719 Semi Annual Voucher Version with NCC	CMS-685.FINAL J 6 D-NW 719 Semi Annual Voucher Version with NCC_20060215.xls	Yes	Yes	Fillable Printable
Form	CMS-685	CMS-685.FINAL J 6 C-NW 719 Monthly Voucher Version with SIMS_20060215.xls	CMS-685.FINAL J 6 C-NW 719 Monthly Voucher Version with SIMS_20060215.xls	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

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

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	36	36
Annual IC Time Burden (Hours)	108	108
Annual IC Cost Burden (Dollars)	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.