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

Medicare Disproportionate Share Hospital (DSH) Payments: Counting Days Associated With Section 1115 Demonstrations in the Medicaid Fraction (CMS-10839)

Documents and Forms

Document Name Document Type
CMS-10839.Instructions for Worksheet S2.pdf Instruction

Information Collection (IC) Details

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

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 %

	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

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.