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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
OMB: 0938-0202
IC ID: 7881
OMB.report
HHS/CMS
OMB 0938-0202
ICR 201106-0938-005
IC 7881
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0202 can be found here:
2020-12-24 - Reinstatement with change of a previously approved collection
2014-10-17 - Reinstatement without change of a previously approved collection
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
View Information Collection (IC)
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
URL
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
Federal Enterprise Architecture Business Reference Module
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
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
1,541
0
0
196
0
1,345
Annual IC Time Burden (Hours)
718,106
0
0
91,336
0
626,770
Annual IC Cost Burden (Dollars)
0
0
0
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.