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⚠️ Notice: This information collection may be referencing outdated material.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
CMS-416 Instructions 8-23-10 clean.docx Instruction
CMS-416 Annual EPSDT Participation Report CHIPRA CMS-416 Form with disclosure.xlsx Form
CMS-416 Instructions 8-23-10 tracked.docx CMS-416 Instructions 8-23-10 tracked IC Document
Crosswalk CHIPRA PRA.docx Crosswalk CHIPRA PRA 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
Instruction			CMS-416 Instructions 8-23-10 clean.docx		Yes	No	Printable Only
Form	CMS-416	Annual EPSDT Participation Report	CHIPRA CMS-416 Form with disclosure.xlsx		Yes	Yes	Fillable Fileable

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: 75 %

	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
CMS-416 Instructions 8-23-10 tracked	CMS-416 Instructions 8-23-10 tracked.docx	09/15/2010
Crosswalk CHIPRA PRA	Crosswalk CHIPRA PRA.docx	09/15/2010

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