Information Collection

Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-21)

IC 7881 under ICR 202408-0938-039 · OMB 0938-0202.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-287-21 Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-21)	Form
r3p248i.docx	Instruction
r3p248i.docx	Instruction
CMS-287-21 Home Office Cost Statement r3p248f.xlsx	Form
CMS-287-21 Home Office Cost Statement r3p248f.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 413.17 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
Form	CMS-287-21	Home Office Cost Statement	r3p248f.xlsx		Yes	Yes	Fillable Fileable Signable
Instruction			r3p248i.docx		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,646

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,646	20	1,626
Annual IC Time Burden (Hours)	767,036	9,320	757,716
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.