Information Collection

Medicaid Disproportionate Share Hospital (DSH) Annual Report

IC 8445 under ICR 202006-0938-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-R-266 Medicaid Disproportionate Share Hospital (DSH) Annual Report	Form
CMS-R-266 Disproportionate Share Hospital (DSH) Annual Report CMS-R-266 - Spreadsheet (rev 11-21-2016)SG1-30 (rev PRA Statement).xls	Form

IC Title:

Medicaid Disproportionate Share Hospital (DSH) Annual Report

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
Form	CMS-R-266	Disproportionate Share Hospital (DSH) Annual Report	CMS-R-266 - Spreadsheet (rev 11-21-2016)SG1-30 (rev PRA Statement).xls		Yes	Yes	Fillable Fileable

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	Previously Approved
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	2,142	2,142
Annual IC Cost Burden (Dollars)	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.