Information Collection

Imposition of Cost Sharing Charges Under Medicaid and Supporting Regulations contained in 42 CFR Section 447.53

IC 8046 under ICR 200707-0938-009 · OMB 0938-0429.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0429 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-53 Imposition of Cost Sharing Charges Under Medicaid and Supporting Regulations contained in 42 CFR Section 447.53	Form and Instruction
CMS-R-53 State Plan Under Title XIX of the Social Security Act Scanned 1916 Cost sharing pages.mdi	Form and Instruction
CMS-R-53 Reponse to Terms of Clearance.doc Response to Terms of Clearance	IC Document

IC Title:

Imposition of Cost Sharing Charges Under Medicaid and Supporting Regulations contained in 42 CFR Section 447.53

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 447.53

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
Form and Instruction	CMS-R-53	State Plan Under Title XIX of the Social Security Act	Scanned 1916 Cost sharing pages.mdi		No	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2	2
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Response to Terms of Clearance	CMS-R-53 Reponse to Terms of Clearance.doc	07/19/2007

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