Independent Renal Dialysis Facility Cost Report and Supporting Regulations 42 CFR 413.20, 42 CFR 413.24 and 42 CFR 413.178

Independent Renal Dialysis Facility Cost Report and Supporting Regulations 42 CFR 413.20 and 42 CFR 413.24

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0236 can be found here:

Documents and Forms

Document Name Document Type
pr2_4200_to_4215 [rev 10-12-11].doc Instruction
pr2_42_toc.doc Instruction
pr2_4295_to_4295 [rev 10-12-11].doc Instruction
CMS-265-11 Independent Renal Dialysis Facility Cost Report CMS-265-11 -- rev 10-12-11.xlsx Form
CMS-265-11Revisions - Crosswalk from old to new.doc Crosswalk IC Document
2011 ESRD Disclosure Statement.DOC 2011 ESRD Disclosure Statement IC Document

Information Collection (IC) Details

IC Title:	Independent Renal Dialysis Facility Cost Report and Supporting Regulations 42 CFR 413.20, 42 CFR 413.24 and 42 CFR 413.178	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 413.24 42 CFR 413.178

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			pr2_4200_to_4215 [rev 10-12-11].doc	Yes	No	Printable Only
Instruction			pr2_42_toc.doc	Yes	No	Printable Only
Instruction			pr2_4295_to_4295 [rev 10-12-11].doc	Yes	No	Printable Only
Form	CMS-265-11	Independent Renal Dialysis Facility Cost Report	CMS-265-11 -- rev 10-12-11.xlsx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,654	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 %

	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	5,654	0	0	146	5,508
Annual IC Time Burden (Hours)	367,510	55,445	27,175	9,490	275,400
Annual IC Cost Burden (Dollars)	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	CMS-265-11Revisions - Crosswalk from old to new.doc	10/12/2011
2011 ESRD Disclosure Statement	2011 ESRD Disclosure Statement.DOC	10/12/2011

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