Provider Relief Fund (PRF) Questioned Cost Attestation Form

COVID–19 Provider Relief Programs Single and Commercial Audits and Delinquent Audit Reporting Submission Activities

Documents and Forms

Document Name Document Type
Form 3 Provider Relief Fund (PRF) Questioned Cost Attestation Form Form and Instruction
3 Questioned Cost Attestation Form Questioned Cost Attestation Form_Final.docx Form and Instruction
3 Questioned Cost Attestation Form Questioned Cost Attestation Form_Final.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Provider Relief Fund (PRF) Questioned Cost Attestation Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	Questioned Cost Attestation Form	Questioned Cost Attestation Form_Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	70,000	70,000
Annual IC Time Burden (Hours)	350,000	350,000
Annual IC Cost Burden (Dollars)	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.