Information Collection

Rural Health Clinic Cost Report (CMS-222-17)

IC 7853 under ICR 202410-0938-004 · OMB 0938-0107.

Documents and Forms

Document Name Document Type
R2P246i.pdf Instruction
R2P246i.pdf Instruction
222-17 Rural Health Clinic Cost Report R2P246f.xlsx Form
222-17 Rural Health Clinic Cost Report R2P246f.xlsx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Rural Health Clinic Cost Report (CMS-222-17)	Agency IC Tracking Number:	CM-FFS

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 413.20 42 CFR 413.24

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			R2P246i.pdf		Yes	No	Printable Only
Form	222-17	Rural Health Clinic Cost Report	R2P246f.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,101	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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,101	377	1,724
Annual IC Time Burden (Hours)	115,555	20,735	94,820
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.