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

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
pr2_39_toc.docx Instruction
pr2_3900_to_3990.docx Instruction
CMS-287-05 Home Office Cost Statement 287-05.xls Form

Information Collection (IC) Details

IC Title:	Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-05)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 413.20 42 CFR 413.17

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			pr2_39_toc.docx	Yes	No	Printable Only
Form	CMS-287-05	Home Office Cost Statement	287-05.xls	Yes	No	Printable Only
Instruction			pr2_3900_to_3990.docx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,541	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 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,541	196	1,345
Annual IC Time Burden (Hours)	718,106	91,336	626,770
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.