OMB control number

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

OMB 0938-0107 · HHS/CMS.

OMB 0938-0107

The Form CMS-222-17 cost report is needed to determine program reimbursement and the amount of reasonable cost due to providers for furnishing medical services to Medicare beneficiaries.

The latest form for Independent Rural Health Clinic Cost Report (CMS-222-17) expires 2027-11-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
CMS 222-17 Supporting Statement.docx Supporting Statement A
Rural Health Clinic Cost Report (CMS-222-17) Instruction

All Historical Document Collections

202410-0938-004	Extension without change of a currently approved collection	2024-10-17
202112-0938-011 Approved without change	Reinstatement without change of a previously approved collection	2022-01-06
201709-0938-008 Approved with change	Revision of a currently approved collection	2017-09-29
201408-0938-001 Approved without change	Extension without change of a currently approved collection	2014-08-28
201106-0938-003 Approved with change	Extension without change of a currently approved collection	2011-06-07
200803-0938-007 Approved without change	Extension without change of a currently approved collection	2008-03-28
200504-0938-010 Approved without change	Extension without change of a currently approved collection	2005-04-29
200208-0938-018 Approved without change	Extension without change of a currently approved collection	2002-08-29
199909-0938-007 Approved without change	Extension without change of a currently approved collection	1999-09-16
199607-0938-003 Approved without change	Revision of a currently approved collection	1996-07-08
199307-0938-001 Approved without change	Revision of a currently approved collection	1993-07-28
199211-0938-009 Approved without change	Reinstatement with change of a previously approved collection	1992-11-30
198905-0938-010 Approved with change	No material or nonsubstantive change to a currently approved collection	1989-05-05
198811-0938-009 Approved without change	Revision of a currently approved collection	1988-11-22
198602-0938-003 Approved without change	Reinstatement with change of a previously approved collection	1986-02-10
198308-0938-006 Approved without change	Reinstatement with change of a previously approved collection	1983-08-25
198212-0938-014 Approved without change	Reinstatement with change of a previously approved collection	1982-12-15
198008-0938-001 Approved without change	New collection (Request for a new OMB Control Number)	1980-08-25