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 201408-0938-013 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-265-11 Independent Renal Dialysis Facility Cost Report and Supporting Regulations 42 CFR 413.20, 42 CFR 413.24 and 42 CFR 413.178	Form
Form CMS-265-11 Instructions.pdf	Instruction
CMS-265-11 Independent Renal Dialysis Facility Cost Report Form CMS-265-11 Forms.xls	Form

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:

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-265-11	Independent Renal Dialysis Facility Cost Report	Form CMS-265-11 Forms.xls		Yes	Yes	Fillable Fileable Signable
Instruction			Form CMS-265-11 Instructions.pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,677

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	5,677	23	5,654
Annual IC Time Burden (Hours)	369,005	1,495	367,510
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.