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⚠️ Notice: This information collection may be referencing outdated material.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
Revised CMS-416-instructions clean 020620.docx Instruction
CMS-416 Annual EPSDT Participation Report CMS416clean 020620 with updated PRA disclosure.xlsx Form
Form CMS-416 - Crosswalk 020620.xlsx Crosswalk - CMS-416 IC Document
CMS-416InstrCrosswalk020620.xlsx Crosswalk - CMS-416 Instructions IC Document
Form CMS-416 redline 020620 with revised PRA statement.xlsx Track Changes - CMS-416 IC Document
Revised CMS-416-instructions redline 020620.docx Track Changes - CMS-416 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	CMS416clean 020620 with updated PRA disclosure.xlsx		Yes	Yes	Fillable Printable
Instruction			Revised CMS-416-instructions clean 020620.docx		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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	56	0	56
Annual IC Time Burden (Hours)	1,512	-112	1,624
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk - CMS-416	Form CMS-416 - Crosswalk 020620.xlsx	02/26/2020
Crosswalk - CMS-416 Instructions	CMS-416InstrCrosswalk020620.xlsx	02/26/2020
Track Changes - CMS-416	Form CMS-416 redline 020620 with revised PRA statement.xlsx	02/26/2020
Track Changes - CMS-416 Instructions	Revised CMS-416-instructions redline 020620.docx	02/26/2020

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