Medicare Provider Cost Report Reimbursement Questionnaire (exhibit 1)

Medicare Provider Cost Report Reimbursement Questionnaire and Supporting Regulations in 42 CFR 413.20, 413.24, and 415.60

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0301 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-339 Medicare Provider Cost Report Reimbursement Questionnaire (exhibit 1) Form and Instruction
CMS-339 Medicare Provider Cost Report Reimbursement Questionnair cms339[1].pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Medicare Provider Cost Report Reimbursement Questionnaire (exhibit 1)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 413.20 42 CFR 413.24 42 CFR 415.60

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-339	Medicare Provider Cost Report Reimbursement Questionnaire	cms339[1].pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 38,429	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	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	38,429	2,525	35,904
Annual IC Time Burden (Hours)	192,145	-411,161	603,306
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.