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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.