Information Collection

Federally Qualified Health Center Cost Report Form

IC 217774 under ICR 202206-0938-016 · OMB 0938-1298.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1298 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-224-14 Federally Qualified Health Center Cost Report Form	Form
Form CMS-224-14 FQHC Cost Report Form (Worksheets) Federally Qualified Health Center Cost Report Form	Form
Form CMS-224-14 FQHC Cost Report Form Federally Qualified Health Center Cost Report Form	Form
R4P244i.pdf	Instruction
R4P244i.pdf	Instruction
CMS-224-14 FQHC Cost Report Form (Worksheets) R4P244f.xlsx	Form
CMS-224-14 FQHC Cost Report Form (Worksheets) R4P244f.xlsx	Form
CMS-224-14 FQHC Cost Report Form R4P244f.pdf	Form
CMS-224-14 FQHC Cost Report Form R4P244f.pdf	Form

IC Title:

Federally Qualified Health Center Cost Report Form

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 413.24 42 CFR 413.20

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-224-14	Yes	Yes	Fillable Fileable
Instruction		Yes	No	Printable Only
Form	CMS-224-14	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,890

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	2,890	650	2,240
Annual IC Time Burden (Hours)	167,620	37,700	129,920
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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