Imposition of Cost Sharing Charges Under Medicaid and Supporting Regulations contained in 42 CFR Section 447.53

Documents and Forms

Document Name Document Type
Form CMS-R-53 Imposition of Cost Sharing Charges Under Medicaid and Supporting Regulations contained in 42 CFR Section 447.53 Form
CMS-R-53 Cost Sharing Scanned 1916 Cost sharing pages.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Imposition of Cost Sharing Charges Under Medicaid and Supporting Regulations contained in 42 CFR Section 447.53	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 447.53

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-53	Cost Sharing	Scanned 1916 Cost sharing pages.pdf		No	No	Printable Only

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: 50 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2	2
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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