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Early Periodic Screening Diagnostic And Treatment (epsdt) Report
EARLY PERIODIC SCREENING DIAGNOSTIC AND TREATMENT (EPSDT) REPORT
OMB: 0938-0291
IC ID: 113367
OMB.report
HHS/CMS
OMB 0938-0291
ICR 198507-0938-007
IC 113367
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0291 can be found here:
1987-07-14 - Extension without change of a currently 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:
EARLY PERIODIC SCREENING DIAGNOSTIC AND TREATMENT (EPSDT) REPORT
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-420
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
54
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
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
216
0
0
0
0
216
Annual IC Time Burden (Hours)
1,944
0
0
-1,210
0
3,154
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.