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

OMB 0938-0270

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 2023-07-31 and can be found here.

Latest Forms, Documents, and Supporting Material
Document
Name
Form and Instruction
Supporting Statement A
All Historical Document Collections
 Reinstatement without change of a previously approved collection 2024-11-05
Approved with change
 Extension without change of a currently approved collection 2020-03-24
Approved with change
 Revision of a currently approved collection 2016-12-23
Approved without change
 Reinstatement without change of a previously approved collection 2013-09-12
Approved without change
 Extension without change of a currently approved collection 2007-09-27
Approved with change
 Extension without change of a currently approved collection 2004-07-14
Approved without change
 Extension without change of a currently approved collection 2001-07-26
Approved without change
 Revision of a currently approved collection 1998-07-09
Approved without change
 Revision of a currently approved collection 1995-07-13
Approved without change
 Reinstatement with change of a previously approved collection 1992-08-17
Approved without change
 Reinstatement with change of a previously approved collection 1990-04-17
Approved without change
 Extension without change of a currently approved collection 1986-10-02
Approved without change
 Extension without change of a currently approved collection 1985-03-19
Approved without change
 New collection (Request for a new OMB Control Number) 1982-11-09
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