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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-222-17 Rural Health Clinic Cost Report Rural Health Clinic Cost Report (CMS-222-17)	Form
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

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction					Yes	No	Printable Only
Form	CMS-222-17				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: 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	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

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.

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