End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0657 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-685 End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112 Form
CMS-685 FINAL_Updated_J_6_A_Instructionsdjr012513.docx.docx Instruction
CMS-685 Network Semi Annual Reprot Network Semi Annual Report xlsx.xlsx Form
Crosswalk ESRD Network Semi Annual Cost Report Forms.doc.doc Crosswalk IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 405.2110 42 CFR 405.2112

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-685	Network Semi Annual Reprot	Network Semi Annual Report xlsx.xlsx		Yes	Yes	Fillable Fileable
Instruction			CMS-685 FINAL_Updated_J_6_A_Instructionsdjr012513.docx.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 18	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	36	36
Annual IC Time Burden (Hours)	108	108
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Crosswalk ESRD Network Semi Annual Cost Report Forms.doc.doc	04/29/2013

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