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Information Collection

Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report

IC 7986 under ICR 202604-0938-013 · OMB 0938-0354.

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IC Document
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Information Collection (IC) Details

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Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report
 
No Modified
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-416 Annual EPSDT Participation Report Form CMS-416 clean_20251120 508.pdf Yes Yes Fillable Printable
Instruction Revised Form CMS-416 Instructions clean 508.pdf No   Printable Only

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 56 0 0 0 0 56
Annual IC Time Burden (Hours) 1,128 0 -384 0 0 1,512
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Form CMS-416 - Crosswalk Form CMS-416 - Crosswalk.pdf 04/15/2026
Form CMS-416 - Redline Form CMS-416 TrackChanges.pdf 04/15/2026
Form CMS-416 Instructions - Crosswalk Form CMS-416 Instructions - Crosswalk.pdf 04/15/2026
Form CMS-416 Instructions - Redline Revised Form CMS-416 Instructions TrackChanges.pdf 04/15/2026
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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