OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report (CMS-416)

OMB 0938-0354 · HHS/CMS.

OMB 0938-0354

States are required to submit an annual report on the provision of EPSDT services to CMS pursuant to section 1902(a)(43)(D) of the Social Security Act. These reports provide CMS with data necessary to assess the effectiveness of State EPSDT programs, to determine a state's results in achieving its participation goal, and to respond to inquiries. Respondents are State Medicaid agencies. The data is due April 1 of every year so States need to have the form and instructions as soon as possible in order to report timely.

The latest form for Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report (CMS-416) expires 2029-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material
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Name
Form
Supporting Statement A
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 Revision of a currently approved collection 2026-04-16
Approved without change
 Extension without change of a currently approved collection 2023-05-24
Approved without change
 Revision of a currently approved collection 2020-02-27
Approved without change
 Revision of a currently approved collection 2017-02-24
Approved without change
 No material or nonsubstantive change to a currently approved collection 2015-07-14
Approved without change
 Revision of a currently approved collection 2013-12-10
Approved with change
 Revision of a currently approved collection 2010-09-30
Approved without change
 Extension without change of a currently approved collection 2010-03-24
Approved without change
 Revision of a currently approved collection 2009-08-31
Approved without change
 Revision of a currently approved collection 2009-03-10
Approved without change
 Extension without change of a currently approved collection 2006-01-26
Approved with change
 Extension without change of a currently approved collection 2002-09-26
Approved without change
 Reinstatement with change of a previously approved collection 1999-05-27
Withdrawn
 Extension without change of a currently approved collection 1999-02-05
Approved without change
 Extension without change of a currently approved collection 1998-07-22
Approved without change
 Extension without change of a currently approved collection 1997-06-25
Approved without change
 Extension without change of a currently approved collection 1995-06-28
Approved without change
 Revision of a currently approved collection 1993-05-13
Approved without change
 Revision of a currently approved collection 1990-04-20
Approved without change
 Revision of a currently approved collection 1987-07-28
Approved without change
 New collection (Request for a new OMB Control Number) 1984-05-17