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)

OMB: 0938-0354

IC ID: 7986

Information Collection (IC) Details

View Information Collection (IC)

Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report
 
No Unchanged
 
Mandatory
 

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

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 56 0 0 0 0 56
Annual IC Time Burden (Hours) 1,568 0 0 0 0 1,568
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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