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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.