Information Collection

Renal Dialysis Facility Cost Report

IC 7893 under ICR 201709-0938-009 · OMB 0938-0236.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0236 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
pr2_42.pdf	Instruction
CMS-265-11 Renal Dialysis Facility Cost Report pr2_42f.pdf	Form

IC Title:

Renal Dialysis Facility Cost Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 413.20 42 CFR 413.24 42 CFR 413.178

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			pr2_42.pdf		Yes	No	Printable Only
Form	CMS-265-11	Renal Dialysis Facility Cost Report	pr2_42f.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: 6,821

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,821	1,144	5,677
Annual IC Time Burden (Hours)	443,365	74,360	369,005
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.