Information Collection

Medicaid Disproportionate Share Hospital Annual Reporting

IC 8445 under ICR 201306-0938-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-R-266 Medicaid Disproportionate Share Hospital Annual Reporting Form
CMS-R-266 Medicaid Disproportionate Share Hospital (DSH) Annual Re Copy of CMS-R-266_Spreadsheet, rev.xls Form
CMS-R-266_Disclosure_Statement, rev.doc CMS-R-266_Disclosure_Statement, rev IC Document
CMS-R-266 - Crosswalk.doc CMS-R-266 - Crosswalk 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
Form	CMS-R-266	Medicaid Disproportionate Share Hospital (DSH) Annual Report	Copy of CMS-R-266_Spreadsheet, rev.xls		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to New Statute	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	51	0	-1	52
Annual IC Time Burden (Hours)	2,142	128	38	1,976
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-R-266_Disclosure_Statement, rev	CMS-R-266_Disclosure_Statement, rev.doc	06/03/2013
CMS-R-266 - Crosswalk	CMS-R-266 - Crosswalk.doc	06/12/2013

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