Information Collection

Skilled Nursing Facility and Silled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106

IC 8084 under ICR 201107-0938-006 · OMB 0938-0463.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0463 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-2540-10 Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Cost Report Certification and Settlement Summary Skilled Nursing Facility and Silled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106	Form
pr2_41_toc.doc	Instruction
pr2_4108_to_4120.doc	Instruction
pr2_4121_to_4130.2.doc	Instruction
pr2_4131_to_4161.doc	Instruction
pr2_4190.doc	Instruction
pr2_4195.doc	Instruction
pr2_4100_to_4107 [rev 07-13-11].doc	Instruction
CMS-2540-10 Skilled Nursing Facility and Skilled Nursing Facility He CMS-2540-10 FORMS.xls	Form
CMS-2540 Crosswalk.xlsx CMS-2540-10 Crosswalk [Added Worksheet]	IC Document
pr2_4195 Crosswalk.doc Instruction, Section 4195 - Crosswalk	IC Document
pr2_4100_to_4107 Crosswalk.doc Instructiom, Section 4105 - Crosswalk	IC Document

IC Title:

Skilled Nursing Facility and Silled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 413.24 42 CFR 413.20

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			pr2_41_toc.doc	Yes	No	Printable Only
Instruction			pr2_4108_to_4120.doc	Yes	No	Printable Only
Instruction			pr2_4121_to_4130.2.doc	Yes	No	Printable Only
Instruction			pr2_4131_to_4161.doc	Yes	No	Printable Only
Instruction			pr2_4190.doc	Yes	No	Printable Only
Instruction			pr2_4195.doc	Yes	No	Printable Only
Form	CMS-2540-10	Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Cost Report Certification and Settlement Summary	CMS-2540-10 FORMS.xls	Yes	Yes	Fillable Fileable
Instruction			pr2_4100_to_4107 [rev 07-13-11].doc	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,701

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: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	15,701	0	0	664	15,037
Annual IC Time Burden (Hours)	3,171,602	94,206	251,216	119,520	2,706,660
Annual IC Cost Burden (Dollars)	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-2540-10 Crosswalk [Added Worksheet]	CMS-2540 Crosswalk.xlsx	07/13/2011
Instruction, Section 4195 - Crosswalk	pr2_4195 Crosswalk.doc	07/14/2011
Instructiom, Section 4105 - Crosswalk	pr2_4100_to_4107 Crosswalk.doc	07/14/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.