Form CMS-416 Annual EPSDT Participation Report {CMS-416} | Pdf Fpdf Doc Docx | Official Federal Forms

 Official Federal Forms /  Centers For Medicare And Medicaid Services /
Form CMS-416 Annual EPSDT Participation Report {CMS-416} | Pdf Fpdf Doc Docx | Official Federal Forms

Form CMS-416 Annual EPSDT Participation Report {CMS-416}

This is a Official Federal Forms form that can be used for Centers For Medicare And Medicaid Services.

Alternate TextLast updated: 8/16/2006

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0354 FORM CMS-416: ANNUAL EPSDT PARTICIPATION REPORT State ___________FY _______ Total 1. Total Individuals Eligible for EPSDT CN MN TOTAL Age Groups <1 1­2* 3­5 6­9 10­14 15­18 19­20 2a. State Periodicity Schedule 2b. Number of Years in Age Group 1 2 3 4 5 4 2 2c. Annualized State Periodicity Schedule 3a. Total Months of Eligibility CN MN TOTAL CN MN TOTAL CN MN TOTAL CN MN TOTAL CN MN TOTAL CN MN TOTAL 3b. Average Period of Eligibility 4. Expected Number of Screenings per Eligible 5. Expected Number of Screenings 6. Total Screens Received 7. Screening Ratio * Includes 12­month visit Note: "CN" - Categorically Needy, "MN" = Medically Needy Form CMS-416 (06/99) American LegalNet, Inc. www.USCourtForms.com State ___________FY _______ Total 8. Total Eligibles Who Should Receive at Least One Initial or Periodic Screen 9. Total Eligibles Receiving at Least One Initial or Periodic Screen 10. Participant Ratio CN MN TOTAL CN MN TOTAL CN MN TOTAL CN MN TOTAL CN MN TOTAL CN MN TOTAL CN MN TOTAL CN MN TOTAL Age Groups <1 1­2* 3­5 6­9 10­14 15­18 19­20 11. Total Eligibles Referred for Corrective Treatment 12a. Total Eligibles Receiving Any Dental Services 12b. Total Eligibles Receiving Preventive Dental Services 12c. Total Eligibles Receiving Dental Treatment Services 13. Total Eligibles Enrolled in Managed Care 14. Total Number of Screening Blood Lead Tests CN MN TOTAL * Includes 12­month visit Note: "CN" - Categorically Needy, "MN" = Medically Needy According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0354. The time required to complete this information collection is estimated to average 19 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Form CMS-416 (06/99) Page 2 American LegalNet, Inc. www.USCourtForms.com

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