Information Collection

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

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-416 Annual EPSDT Participation Report Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report	Form
Revised Form CMS-416 Instructions clean 508.pdf	Instruction
CMS-416 Annual EPSDT Participation Report Form CMS-416 clean_20251120 508.pdf	Form
Form CMS-416 - Crosswalk.pdf Form CMS-416 - Crosswalk	IC Document
Form CMS-416 TrackChanges.pdf Form CMS-416 - Redline	IC Document
Form CMS-416 Instructions - Crosswalk.pdf Form CMS-416 Instructions - Crosswalk	IC Document
Revised Form CMS-416 Instructions TrackChanges.pdf Form CMS-416 Instructions - Redline	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

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-416				Yes	Yes	Fillable Printable
Instruction					No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

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
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	56	0	56
Annual IC Time Burden (Hours)	1,128	-384	1,512
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Form CMS-416 - Crosswalk		04/15/2026
Form CMS-416 - Redline		04/15/2026
Form CMS-416 Instructions - Crosswalk		04/15/2026
Form CMS-416 Instructions - Redline		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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