Information Collection

Amendment To State Plan, Regulation "freedom Of Choice: Waivers And Exceptions To State Plan Restrictions

IC 113065 under ICR 198110-0938-001 · OMB 0938-0193.

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Information Collection (IC) Details

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IC Title:	AMENDMENT TO STATE PLAN, REGULATION "FREEDOM OF CHOICE: WAIVERS AND EXCEPTIONS TO STATE PLAN RESTRICTIONS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-179				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 54	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	702	54	648
Annual IC Time Burden (Hours)	1,290	54	1,236
Annual IC Cost Burden (Dollars)	0	0	0

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