Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-21)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0202 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-287-21 Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-21) Form
R1P248i.pdf Instruction
CMS-287-21 Home Office Cost Statement R1P248f.xlsx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-21)	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 413.17 42 CFR 413.24

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-287-21	Home Office Cost Statement	R1P248f.xlsx		Yes	Yes	Fillable Fileable Signable
Instruction			R1P248i.pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,626	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 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,626	-60	1,686
Annual IC Time Burden (Hours)	757,716	-27,960	785,676
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.