Information Collection

Skilled Nursing Facility and Silled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106

IC 8084 under ICR 201408-0938-012 · OMB 0938-0463.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0463 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-2540-10 Skilled Nursing Facility and Silled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106	Form
pr2_41.pdf	Instruction
CMS-2540-10 SKILLED NURSING FACILITY AND SKILLED NURSING FACILITY HE R5p241F.pdf	Form
CMS-2540 Crosswalk.xlsx CMS-2540-10 Crosswalk [Added Worksheet]	IC Document
pr2_4195 Crosswalk.doc Instruction, Section 4195 - Crosswalk	IC Document
pr2_4100_to_4107 Crosswalk.doc Instructiom, Section 4105 - Crosswalk	IC Document

IC Title:

Skilled Nursing Facility and Silled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 413.24 42 CFR 413.20

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-2540-10	SKILLED NURSING FACILITY AND SKILLED NURSING FACILITY HEALTH CARE COMPLEX COST REPORT	R5p241F.pdf		Yes	Yes	Fillable Fileable Signable
Instruction			pr2_41.pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 14,185

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	14,185	-1,516	15,701
Annual IC Time Burden (Hours)	2,865,370	-306,232	3,171,602
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-2540-10 Crosswalk [Added Worksheet]	CMS-2540 Crosswalk.xlsx	07/13/2011
Instruction, Section 4195 - Crosswalk	pr2_4195 Crosswalk.doc	07/14/2011
Instructiom, Section 4105 - Crosswalk	pr2_4100_to_4107 Crosswalk.doc	07/14/2011

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