Data Element Report

Medicaid Disproportionate Share Hospital (DSH) Annual Reporting Requirements (CMS-R-266)

⚠️ Notice: This information collection may be referencing outdated material.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 Data Element Report Form
CMS-R-266 Data Element Report Data Element Report (CMS-R-266, CMS-2445-P version 1).pdf Form
CMS-R-266 Data Element Report Data Element Report (CMS-R-266, CMS-2445-P version 1).pdf Form
CMS-R-266 Crosswalk: Data Element Report Crosswalk - Data Element Report (CMS-R-266, CMS-2445-P version 1).pdf Form and Instruction
CMS-R-266 Crosswalk: Data Element Report Crosswalk - Data Element Report (CMS-R-266, CMS-2445-P version 1).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Data Element 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	Data Element Report	Data Element Report (CMS-R-266, CMS-2445-P version 1).pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-266	Crosswalk: Data Element Report	Crosswalk - Data Element Report (CMS-R-266, CMS-2445-P version 1).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	50	0	-1	51
Annual IC Time Burden (Hours)	2,250	150	-42	2,142
Annual IC Cost Burden (Dollars)	0	0	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.