Transcription of FORM CMS-416: ANNUAL EPSDT PARTICIPATION REPORT
1 Form CMS-416 (06/99)DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESForm ApprovedOMB No. 0938-0354 FORM CMS-416: ANNUAL EPSDT PARTICIPATION REPORTS tate _____FY _____Age GroupsTotal<11 2*3 56 910 1415 1819 201. Total IndividualsEligible for EPSDT2a. State PeriodicitySchedule2b. Number of Yearsin Age Group2c. Annualized StatePeriodicity Schedule3a. Total Monthsof Eligibility3b. Average Periodof Eligibility4. Expected Number ofScreenings perEligible5. Expected Numberof Screenings6. Total ScreensReceived7. Screening RatioCNMNTOTALCNMNTOTALCNMNTOTALCNMNTOTA LCNMNTOTALCNMNTOTALCNMNTOTAL1234542*Incl udes 12 month visitNote: CN - Categorically Needy, MN = Medically NeedyForm CMS-416 (06/99)Page 2 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.
2 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 andreview 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 _____FY _____Age GroupsTotal<11 2*3 56 910 1415 1819 208. Total Eligibles WhoShould Receive atLeast One Initial orPeriodic Screen9. Total EligiblesReceiving at LeastOne Initial orPeriodic Screen10. Participant EligiblesReferred forCorrective Treatment12a.
3 Total EligiblesReceiving AnyDental Services12b. Total EligiblesReceiving PreventiveDental Services12c. Total EligiblesReceiving DentalTreatment Services13. Total Eligibles Enrolled in Managed Care14. Total Number ofScreening BloodLead TestsCNMNTOTAL*Includes 12 month visitNote: CN - Categorically Needy, MN = Medically NeedyCNMNTOTALCNMNTOTALCNMNTOTALCNMNTOTA LCNMNTOTALCNMNTOTALCNMNTOTALCNMNTOTAL
