Information Collection

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

IC 7893 under ICR 201110-0938-007 · OMB 0938-0236.

⚠️ Notice: This information collection may be referencing outdated material.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

View Information Collection (IC)

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.