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)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-416 Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report Form
416 instructions revised per 60-day public comments.pdf Instruction
CMS-416 Annual EPSDT Participation Report CMS_416_2010_508.pdf Form
PRA Crosswalk 2014 CMS-416 instructions.pdf Crosswalk for Instructions IC Document

Information Collection (IC) Details

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
Form	CMS-416	Annual EPSDT Participation Report	CMS_416_2010_508.pdf		Yes	Yes	Fillable Printable
Instruction			416 instructions revised per 60-day public comments.pdf		Yes	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: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	56	0	56
Annual IC Time Burden (Hours)	1,568	0	1,568
Annual IC Cost Burden (Dollars)	0	-15,000	15,000

Documents for IC

Title	Document	Date Uploaded
Crosswalk for Instructions	PRA Crosswalk 2014 CMS-416 instructions.pdf	12/09/2013

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