Information Collection

Medicaid Statistical Information System (CMS-R-284)

IC 7980 under ICR 200702-0938-001 · OMB 0938-0345.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0345 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
msisdd99v5e.doc	Other-Other
SMM2700.doc	Instruction
NPI-final rule.pdf NPI Final Rule	IC Document
PUBLIC LAW 104-hipaa.doc Public Law 104-HIPAA	IC Document
bbalaw.doc BBA Law	IC Document
mmalaw.doc MMA Law	IC Document

IC Title:

Medicaid Statistical Information System (CMS-R-284)

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Other			msisdd99v5e.doc		Yes	Yes	Fillable Fileable
Instruction			SMM2700.doc		No	No	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 53

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	212	0	212
Annual IC Time Burden (Hours)	2,544	424	2,120
Annual IC Cost Burden (Dollars)	0	-64,000	64,000

Documents for IC

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.