Information Collection

Medicaid Disproportionate Share Hospital Annual Reporting

IC 8445 under ICR 201401-0938-019 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Copy of CMS-R-266_Spreadsheet rev.xls	Other-Template
CMS-R-266_Disclosure_Statement [rev 1-30-2014].doc	Other-PRA Disclosure Statement
CMS-R-266 - Crosswalk.doc Crosswalk	IC Document

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Template			Copy of CMS-R-266_Spreadsheet rev.xls		Yes	Yes	Fillable Printable
Other-PRA Disclosure Statement			CMS-R-266_Disclosure_Statement [rev 1-30-2014].doc		Yes	No	Printable Only

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 %

table that charts list of burden
	Approved	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	204	-38	1,976
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	CMS-R-266 - Crosswalk.doc	01/30/2014

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