Information Collection

Medicare Disproportionate Share Hospital (DSH) Payments: Counting Days Associated with Section 1115 Demonstrations in the Medicaid Fraction

IC 260509 under ICR 202308-0938-014 · OMB 0938-1447.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10839.Instructions for Worksheet S2.pdf	Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 412.106

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
Instruction			CMS-10839.Instructions for Worksheet S2.pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 340

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,904,968	1,904,968
Annual IC Time Burden (Hours)	494,536	494,536
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.