Information Collection

Medicaid Disproportionate Share Hospital (DSH) Annual Report

IC 8445 under ICR 202404-0938-003 · OMB 0938-0746.

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 Data Element Report Template CMS-R-266_spreadsheet_DSHauditrevision_CMS-2445-F version 3.xlsx	Form
CMS-R-266 Data Element Report Template CMS-R-266_spreadsheet_DSHauditrevision_CMS-2445-F version 3.xlsx	Form
CMS2445P_spreadsheetPRAupdate_Crosswalk_CMS-2445-F .xlsx Crosswalk: Data Element Report Template	IC Document
CMS2445P_spreadsheetPRAupdate_Crosswalk_CMS-2445-F .xlsx Crosswalk: Data Element Report Template	IC Document
CMS-R-266_spreadsheet_DSHauditrevision_CMS-2445-F version 3 Redline.pdf Redline: Data Element Report Template	IC Document
CMS-R-266_spreadsheet_DSHauditrevision_CMS-2445-F version 3 Redline.pdf Redline: Data Element Report Template	IC Document

IC Title:

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	Data Element Report Template	CMS-R-266_spreadsheet_DSHauditrevision_CMS-2445-F version 3.xlsx		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 %

table that charts list of burden
	Approved	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

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk: Data Element Report Template	CMS2445P_spreadsheetPRAupdate_Crosswalk_CMS-2445-F .xlsx	04/03/2024
Redline: Data Element Report Template	CMS-R-266_spreadsheet_DSHauditrevision_CMS-2445-F version 3 Redline.pdf	04/03/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.