Information Collection

Medicaid Statistical Information System (CMS-R-284)

IC 7980 under ICR 200911-0938-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicaid Statistical Information System (CMS-R-284)	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
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: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	204	-8	212
Annual IC Time Burden (Hours)	2,040	-504	2,544
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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