Information Collection

Medicaid Disproportionate Share Hospital Annual Reporting

IC 8445 under ICR 201104-0938-006 · OMB 0938-0746.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0746 can be found here:

Documents and Forms

Document Name Document Type
CMS-R-266 Spreadsheet.xls Other-Spreadsheet
CMS-R-266 Disclosure Statement.DOC CMS-R-266 Disclosure Statement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicaid Disproportionate Share Hospital Annual Reporting	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 447.299(c)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Spreadsheet			CMS-R-266 Spreadsheet.xls		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 52	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	52	52
Annual IC Time Burden (Hours)	1,976	1,976
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-R-266 Disclosure Statement	CMS-R-266 Disclosure Statement.DOC	04/25/2011

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