Medicare Provider Cost Report Reimbursement Questionnaire (exhibit 1)

Medicare Provider Cost Report Reimbursement Questionnaire and Supporting Regulations in 42 CFR 413.20, 413.24, and 415.60

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-339 Medicare Provider Cost Report Reimbursement Questionnaire (exhibit 1) Form and Instruction
CMS-339 Medicare Provider Cost Report Reimbursement Questionnair cms339[1].pdf Form and Instruction
CMS-276 Exhibits 1&2 Form-CMS-339 Exhibits 2012.pdf Form

Information Collection (IC) Details

IC Title:	Medicare Provider Cost Report Reimbursement Questionnaire (exhibit 1)	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:

Document Type	Form No.	Form Name	Instrument File	URL	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 1&2	Form-CMS-339 Exhibits 2012.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 17,939	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 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	17,939	-20,490	38,429
Annual IC Time Burden (Hours)	53,817	-138,328	192,145
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.