Information Collection

Medicare Provider Cost Report Reimbursement Questionnaire (Exhibit 1)

IC 37886 under ICR 201704-0938-004 · OMB 0938-0301.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-339 Medicare Provider Cost Reimbursement Questionnaire - Exhibit 1 Medicare Provider Cost Report Reimbursement Questionnaire (Exhibit 1)	Form and Instruction
CMS-339 Medicare Provider Cost Reimbursement Questionnaire - Exh CMS-339 PRM-2 Chapter 11 Transmittal 8 - FINAL (Form and Instruction with Exp Date).docx	Form and Instruction

IC Title:

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 415.60 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 and Instruction	CMS-339				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: Not-for-profit institutions, Businesses or other for-profits

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	2,273	-15,666	17,939
Annual IC Time Burden (Hours)	6,819	-46,998	53,817
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].