Information Collection

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

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.