Information Collection

Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report

IC 7986 under ICR 201702-0938-010 · OMB 0938-0354.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-416 Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report	Form
Clean CMS instructions for Form 416 [rev 02-23-2017 by OSORA PRA].pdf	Instruction
CMS-416 Annual EPSDT Participation Report Form_CMS_416_2016_version [rev 02-23-2107 by OSORA PRA).pdf	Form

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:

table that charts list of 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	Form_CMS_416_2016_version [rev 02-23-2107 by OSORA PRA).pdf		Yes	Yes	Fillable Printable
Instruction			Clean CMS instructions for Form 416 [rev 02-23-2017 by OSORA PRA].pdf		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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	56	0	56
Annual IC Time Burden (Hours)	1,624	56	1,568
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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