Information Collection

Medicare Provider Cost Report Reimbursement Questionnaire (exhibit 2 --formerly exhibit 5)

IC 188369 under ICR 201305-0938-011 · OMB 0938-0301.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0301 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-339 Medicare Provider Cost Report Reimbursement Questionnaire (exhibit 2 --formerly exhibit 5)	Form and Instruction
Form CMS 339 Instructions 2012.pdf	Instruction
CMS-339 Medicare Provider Cost Report Reimbursement Questionnair cms339[1].pdf	Form and Instruction
CMS-276 Exhibits Form-CMS-339 Exhibits 2012.pdf	Form
CMS-276 Manual Form CMS-339 Transmittal 7. doc.pdf	Form and Instruction
CMS-276 Index and Instruction Form CMS-339 Index 2012.pdf	Form and Instruction

IC Title:

Medicare Provider Cost Report Reimbursement Questionnaire (exhibit 2 --formerly exhibit 5)

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 413.20 42 CFR 413.24 42 CFR 415.60

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
Form and Instruction	CMS-339	Medicare Provider Cost Report Reimbursement Questionnaire	cms339[1].pdf	Yes	Yes	Fillable Fileable
Form	CMS-276	Exhibits	Form-CMS-339 Exhibits 2012.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-276	Manual	Form CMS-339 Transmittal 7. doc.pdf	Yes	Yes	Fillable Printable
Instruction			Form CMS 339 Instructions 2012.pdf	Yes	No	Printable Only
Form and Instruction	CMS-276	Index and Instruction	Form CMS-339 Index 2012.pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,452

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 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	5,452	4,144	1,308
Annual IC Time Burden (Hours)	21,808	15,268	6,540
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.