OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376 (CMS-379 )

OMB 0938-0270 · HHS/CMS.

OMB 0938-0270

This form is used to collect financial information which is needed to evaluate requests from physicians/suppliers to pay indebetedness under an extended repayment schedule, or to compromise a debt less than the full amount.

The latest form for The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376 (CMS-379 ) expires 2027-12-31 and is listed under ICR 202408-0938-035.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CMS-379 The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376Form and Instruction
CMS-379 Debtor Financials Supporting Statement A .docxSupporting Statement A
The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376 Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202408-0938-035 Reinstatement without change of a previously approved collection 2024-11-05
202003-0938-017 Extension without change of a currently approved collection 2020-03-24 Approved with change
201612-0938-002 Revision of a currently approved collection 2016-12-23 Approved with change
201309-0938-011 Reinstatement without change of a previously approved collection 2013-09-12 Approved without change
200709-0938-010 Extension without change of a currently approved collection 2007-09-27 Approved without change
200407-0938-002 Extension without change of a currently approved collection 2004-07-14 Approved with change
200107-0938-013 Extension without change of a currently approved collection 2001-07-26 Approved without change
199807-0938-002 Revision of a currently approved collection 1998-07-09 Approved without change
199507-0938-001 Revision of a currently approved collection 1995-07-13 Approved without change
199208-0938-001 Reinstatement with change of a previously approved collection 1992-08-17 Approved without change
199004-0938-003 Reinstatement with change of a previously approved collection 1990-04-17 Approved without change
198610-0938-002 Extension without change of a currently approved collection 1986-10-02 Approved without change
198503-0938-016 Extension without change of a currently approved collection 1985-03-19 Approved without change
198211-0938-003 New collection (Request for a new OMB Control Number) 1982-11-09 Approved without change