Information Collection

Fee-For-Service (FFS) Survey

IC 194257 under ICR 202505-0938-018 · OMB 0938-0732.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-246 Fee-For-Service (FFS) Survey	Form and Instruction
Form CMS-R-246 Fee-For-Service (FFS) Survey Fee-For-Service (FFS) Survey	Form and Instruction
CMS-R-246 Fee-For-Service (FFS) Survey 2026-FFS-Survey- clean.docx	Form and Instruction
CMS-R-246 Fee-For-Service (FFS) Survey 2026-FFS-Survey- clean.docx	Form and Instruction
2026-FFS-Survey-REDLINE.pdf Track Change Version FFS	IC Document
2026-FFS-Survey-REDLINE.pdf Track Change Version FFS	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 423.159 42 CFR 422.152(b)

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-R-246				No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Privacy Act of 1974: HPMS # 09-70-4004

FR Citation: 63 FR 43187

Number of Respondents: 275,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	275,000	275,000
Annual IC Time Burden (Hours)	68,750	68,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change Version FFS		06/05/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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