Information Collection

The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376

IC 7924 under ICR 202408-0938-035 · OMB 0938-0270.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-379 The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376	Form and Instruction
CMS-379 Financial Statement Debtor Financial Statement 2019of Debtor v2.pdf	Form and Instruction
CMS-379 Financial Statement Debtor Financial Statement 2019of Debtor v2.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 32 CFR 902.2(g) 32 CFR 901.8(a) 42 CFR 405.376(g)

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
Form and Instruction	CMS-379	Financial Statement Debtor	Financial Statement 2019of Debtor v2.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	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.