Information Collection

Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-05)

IC 7881 under ICR 201410-0938-012 · OMB 0938-0202.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0202 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-287-05_pr2_39_toc.pdf	Instruction
CMS-287-05_pr2_3900_to_3990.pdf	Instruction
CMS-287-05 Home Office Cost Report Form_CMS-287-05.pdf	Form

IC Title:

Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-05)

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 413.17

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
Instruction			CMS-287-05_pr2_39_toc.pdf	Yes	No	Printable Only
Form	CMS-287-05	Home Office Cost Report	Form_CMS-287-05.pdf	Yes	No	Fillable Fileable Signable
Instruction			CMS-287-05_pr2_3900_to_3990.pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,686

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	1,686	145	1,541
Annual IC Time Burden (Hours)	785,676	67,570	718,106
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.