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Provider Cost Report Reimbursement Questionnaire
PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE
OMB: 0938-0301
IC ID: 113389
OMB.report
HHS/CMS
OMB 0938-0301
ICR 198308-0938-014
IC 113389
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0301 can be found here:
2017-04-20 - Reinstatement with change of a previously approved collection
2016-11-23 - Reinstatement without change of a previously approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Migrated
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
HCFA-339
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
15,500
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
15,500
0
15,500
0
0
0
Annual IC Time Burden (Hours)
310,000
0
310,000
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.