View Information Collection (IC)

View Information Collection (IC)

IC Title:	Medicaid Disproportionate Share Hospital Annual Reporting	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Template			Copy of CMS-R-266_Spreadsheet rev.xls		Yes	Yes	Fillable Printable
Other-PRA Disclosure Statement			CMS-R-266_Disclosure_Statement [rev 1-30-2014].doc		Yes	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	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	51	0	0	-1	0	52
Annual IC Time Burden (Hours)	2,142	204	0	-38	0	1,976
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	CMS-R-266 - Crosswalk.doc	01/30/2014

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