Information Collection

Health Care Prepayment Plans (HCPPs) under Section 1833

IC 43653 under ICR 202507-0938-025 · OMB 0938-0165.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-276 4th Quarter Interim Cost Report Health Care Prepayment Plans (HCPPs) under Section 1833	Form
Form CMS-276 Budget Forecast Health Care Prepayment Plans (HCPPs) under Section 1833	Form
Form CMS-276 Interim Cost Report Health Care Prepayment Plans (HCPPs) under Section 1833	Form
Form CMS-276 Final Cost Report Health Care Prepayment Plans (HCPPs) under Section 1833	Form
C. Cost Report Instructions CLEAN 508.pdf	Instruction
C. Cost Report Instructions CLEAN 508.pdf	Instruction
CMS-276 4th Quarter Interim Cost Report K. 4th Quarter Interim Cost Report - Revised 508.pdf	Form
CMS-276 4th Quarter Interim Cost Report K. 4th Quarter Interim Cost Report - Revised 508.pdf	Form
CMS-276 Budget Forecast E. Budget Forecast- Revised 508.pdf	Form
CMS-276 Budget Forecast E. Budget Forecast- Revised 508.pdf	Form
CMS-276 Interim Cost Report H. Interim Cost Report - Revised VJ508.pdf	Form
CMS-276 Interim Cost Report H. Interim Cost Report - Revised VJ508.pdf	Form
CMS-276 Final Cost Report N. Final Cost Report PDF 508.pdf	Form
CMS-276 Final Cost Report N. Final Cost Report PDF 508.pdf	Form
C. Cost Report Instruction Crosswalk 508.pdf Crosswalk: Instructions	IC Document
C. Cost Report Instruction Crosswalk 508.pdf Crosswalk: Instructions	IC Document
F. Budget Forecast Crosswalk 508.pdf Crosswalk: Budget Forecast	IC Document
F. Budget Forecast Crosswalk 508.pdf Crosswalk: Budget Forecast	IC Document
I. Interim Cost Report Crosswalk 508.pdf Crosswalk: Interim Cost Report	IC Document
I. Interim Cost Report Crosswalk 508.pdf Crosswalk: Interim Cost Report	IC Document
L. 4thQtrInterim Revised Cost Rep Crosswalk 508.pdf Crosswalk: 4th Quarter Interim Cost Report	IC Document
L. 4thQtrInterim Revised Cost Rep Crosswalk 508.pdf Crosswalk: 4th Quarter Interim Cost Report	IC Document
O. Final Cost Report Crosswalk 508.pdf Crosswalk: Final Cost Report	IC Document
O. Final Cost Report Crosswalk 508.pdf Crosswalk: Final Cost Report	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Health Care Prepayment Plans (HCPPs) under Section 1833

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 417.808 42 CFR 417.810

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction		Yes	No	Fillable Fileable
Form	CMS-276	Yes	Yes	Fillable Fileable
Form	CMS-276	Yes	Yes	Fillable Fileable
Form	CMS-276	Yes	Yes	Fillable Fileable
Form	CMS-276	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	18	-6	24
Annual IC Time Burden (Hours)	480	-160	640
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk: Instructions		07/29/2025
Crosswalk: Budget Forecast		07/29/2025
Crosswalk: Interim Cost Report		07/29/2025
Crosswalk: 4th Quarter Interim Cost Report		07/29/2025
Crosswalk: Final Cost Report		07/29/2025

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

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