Information Collection

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

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 222-17 Rural Health Clinic Cost Report Rural Health Clinic Cost Report (CMS-222-17)	Form
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

IC Title:

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:

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	222-17				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 %

table that charts list of burden
	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

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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