Information Collection

Federally Qualified Health Center Cost Report Form

IC 217774 under ICR 201508-0938-003 · OMB 0938-1298.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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-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 %

table that charts list of burden
	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

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.