Information Collection

Renal Dialysis Facility Cost Report

IC 7893 under ICR 202205-0938-001 · OMB 0938-0236.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-265-11 Renal Dialysis Facility Cost Report Renal Dialysis Facility Cost Report	Form
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

IC Title:

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:

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-265-11				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 %

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	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

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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