Organ Procurement Organization/Histcompatibility Laboratory Statement of Reimbursable Costs, Manual Instructions (CMS-216-94)

Organ Procurement Organization/Histocompatibility Laboratory Cost Report (CMS-216-94)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0102 can be found here:

Documents and Forms

Document Name Document Type
pr2_33 AC030817_dmr031017_ac031017.pdf Instruction
CMS-216-94 Organ Procuremnet Organization/Histocompatibility Labora R6P233f_AC030817 (002).pdf Form
CMS-216-94 Data and Certification Statement R6P233f_AC030817.xls Form

Information Collection (IC) Details

IC Title:	Organ Procurement Organization/Histcompatibility Laboratory Statement of Reimbursable Costs, Manual Instructions (CMS-216-94)	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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			pr2_33 AC030817_dmr031017_ac031017.pdf	Yes	No	Printable Only
Form	CMS-216-94	Organ Procuremnet Organization/Histocompatibility Laboratory Cost Report	R6P233f_AC030817 (002).pdf	Yes	Yes	Fillable Fileable Signable
Form	CMS-216-94	Data and Certification Statement	R6P233f_AC030817.xls	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 102	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 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	102	-5	107
Annual IC Time Burden (Hours)	4,590	-225	4,815
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.