Information Collection

Medicare Provider Cost Report Reimbursement Questionnaire (exhibit 2 --formerly exhibit 5)

IC 188369 under ICR 201611-0938-006 · OMB 0938-0301.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0301 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-339 Medicare Provider Cost Report Reimbursement Questionnaire (exhibit 2 --formerly exhibit 5)	Form and Instruction
CMS-339 Medicare Provider Cost Report Reimbursement Questionnair PRM-2 Chapter 11 Transmittal 9 vj508.pdf	Form and Instruction

IC Title:

Medicare Provider Cost Report Reimbursement Questionnaire (exhibit 2 --formerly exhibit 5)

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 413.24 42 CFR 415.60 42 CFR 413.20

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 and Instruction	CMS-339	Medicare Provider Cost Report Reimbursement Questionnaire	PRM-2 Chapter 11 Transmittal 9 vj508.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,273

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
	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,273	-3,179	5,452
Annual IC Time Burden (Hours)	9,092	-12,716	21,808
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.