The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376

The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376 (CMS-379 )

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0270 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-379 The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376 Form and Instruction
CMS-379 Financial Statement Debtor Financial Statement 2019of Debtor v2.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 32 CFR 902.2(g) 32 CFR 901.8(a) 42 CFR 405.376(g)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-379	Financial Statement Debtor	Financial Statement 2019of Debtor v2.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	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.