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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 7986 under ICR 201009-0938-018 · OMB 0938-0354.

Documents and Forms
Document Name
Document Type
Instruction
Form
IC Document
IC Document
Information Collection (IC) Details

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Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report
 
No Modified
 
Mandatory
 

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

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   75 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 56 0 0 0 0 56
Annual IC Time Burden (Hours) 1,568 0 0 0 0 1,568
Annual IC Cost Burden (Dollars) 15,000 0 0 0 0 15,000

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.