Information Collection

Rural Health Clinic Cost Report (CMS-222-17)

IC 7853 under ICR 202112-0938-011 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
R2P246i.pdf Instruction
R2P246i.pdf Instruction
CMS-222-17 Rural Health Clinic Cost Report R2P246f.xlsx Form
CMS-222-17 Rural Health Clinic Cost Report R2P246f.xlsx Form

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			R2P246i.pdf		Yes	No	Printable Only
Form	CMS-222-17	Rural Health Clinic Cost Report	R2P246f.xlsx		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,724	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 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,724	-20	1,744
Annual IC Time Burden (Hours)	94,820	-1,100	95,920
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.