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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)
OMB: 0938-0354
IC ID: 7986
OMB.report
HHS/CMS
OMB 0938-0354
ICR 201009-0938-018
IC 7986
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0354 can be found here:
2023-05-24 - Extension without change of a currently approved collection
2020-02-27 - Revision of a currently approved collection
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
View Information Collection (IC)
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
Federal Enterprise Architecture Business Reference Module
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
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
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.