End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112

(CMS-685) End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0657 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-685 End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112 Form and Instruction
ESRD_Network_Semi-Annual_Cost_Reporting_Instructions.docx Instruction
CMS-685 Network Semi-Annual Report 2016_Network_Semi_Annual_Report.xlsx Form and Instruction
2016_Crosswalk_ESRD_Network_Semi Annual_Cost_Report_Forms.doc Crosswalk IC Document

Information Collection (IC) Details

IC Title:	End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 405.2110 42 CFR 405.2112

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-685	Network Semi-Annual Report	2016_Network_Semi_Annual_Report.xlsx		Yes	Yes	Fillable Fileable
Instruction			ESRD_Network_Semi-Annual_Cost_Reporting_Instructions.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 18	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	36	36
Annual IC Time Burden (Hours)	108	108
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	2016_Crosswalk_ESRD_Network_Semi Annual_Cost_Report_Forms.doc	05/10/2016

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