Information Collection

Renal Dialysis Facility Cost Report

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-265-11				Yes	Yes	Fillable Fileable
Instruction					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 %

table that charts list of burden
	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

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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].