Information Collection

Renal Dialysis Facility Cost Report

IC 7893 under ICR 202508-0938-016 · OMB unassigned.

Documents and Forms

Document Name Document Type
Form CMS-265-11 Independent Renal Dialysis Facility Cost Report Renal Dialysis Facility Cost Report Form
CMS-265-11 Instructions.docx Instruction
CMS-265-11 Independent Renal Dialysis Facility Cost Report CMS-265-11 Form.xlsx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Renal Dialysis Facility Cost Report	Agency IC Tracking Number:	CM-FFS

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 413.20 42 CFR 413.24 42 CFR 413.178

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-265-11	Independent Renal Dialysis Facility Cost Report	CMS-265-11 Form.xlsx		Yes	Yes	Fillable Fileable
Instruction			CMS-265-11 Instructions.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,329	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	7,329	-212	7,541
Annual IC Time Burden (Hours)	483,714	-13,992	497,706
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.

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