Renal Dialysis Facility Cost Report

Independent Renal Dialysis Facility Cost Report (CMS-265-11)

Documents and Forms

Document Name Document Type
r6P242i.pdf Instruction
R6P242i.docx Instruction
CMS-265-11 Renal Dialysis Facility Cost Report r6P242f.pdf Form
CMS-265-11 Renal Dialysis Facility Cost Report R6P242f.xlsx Form

Information Collection (IC) Details

IC Title:	Renal Dialysis Facility Cost Report	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 413.24 42 CFR 413.178

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			R6P242i.docx		Yes	No	Printable Only
Form	CMS-265-11	Renal Dialysis Facility Cost Report	R6P242f.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: 7,541	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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	7,541	720	6,821
Annual IC Time Burden (Hours)	497,706	54,341	443,365
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.