Information Collection

Rural Health Clinic Cost Report CMS-222-17

IC 7853 under ICR 201709-0938-008 · OMB 0938-0107.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0107 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
R1P246_222-17.pdf	Instruction
CMS-222-17 Rural Health Clinic Cost Report R1P246f_222.pdf	Form

IC Title:

Rural Health Clinic Cost Report CMS-222-17

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 413.20 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
Instruction			R1P246_222-17.pdf		Yes	No	Printable Only
Form	CMS-222-17	Rural Health Clinic Cost Report	R1P246f_222.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,744

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: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,744	-1,520	3,264
Annual IC Time Burden (Hours)	95,920	-67,280	163,200
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.