Federally Qualified Health Center Cost Report Form

Federally Qualified Health Center Cost Report Form (CMS-224-14)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1298 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-224-14 Federally Qualified Health Center Cost Report Form Form
CMS-224_Supplementary_Document_(Instructions).pdf Instruction
CMS-224-14 FQHC Cost Report Form (Worksheets) CMS-224-14_Worksheets(30-day).xlsx Form

Information Collection (IC) Details

IC Title:	Federally Qualified Health Center Cost Report Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 413.20 42 CFR 413.24

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-224-14	FQHC Cost Report Form (Worksheets)	CMS-224-14_Worksheets(30-day).xlsx		Yes	Yes	Fillable Fileable
Instruction			CMS-224_Supplementary_Document_(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: 1,296	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 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	1,296	1,296
Annual IC Time Burden (Hours)	75,168	75,168
Annual IC Cost Burden (Dollars)	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.