Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report

Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report (CMS-416)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0354 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-416 Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report Form
CMS 416 instructions updated.doc Instruction
CMS-416 Annual EPSDT Participation Report CMS-416 Form updated 3 page.XLS Form
CMS 416 instructions updated tracked.doc Track Change Document of revised Instructions IC Document
Crosswalk document for Changes.doc Crosswalk document for Changes IC Document

Information Collection (IC) Details

IC Title:	Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report	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	CMS-416	Annual EPSDT Participation Report	CMS-416 Form updated 3 page.XLS		No	No	Fillable Printable
Instruction			CMS 416 instructions updated.doc		No	No	Paper Only

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: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	1,568	1,568
Annual IC Cost Burden (Dollars)	15,000	15,000

Documents for IC

Title	Document	Date Uploaded
Track Change Document of revised Instructions	CMS 416 instructions updated tracked.doc	02/25/2009
Crosswalk document for Changes	Crosswalk document for Changes.doc	02/25/2009

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