Information Collection

Alternative Benefits State Plan Amendment HOA Demonstration Program (CMS-10216)

IC 46477 under ICR 200612-0938-006 · OMB 0938-1007.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1007 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10216 Alternative Benefits State Plan Amendment HOA Demonstration Program (CMS-10216)	Form
HOA SMD112906.doc	Instruction
CMS-10216 HOA Preprint HOA preprint 11-29-06.doc	Form

IC Title:

Alternative Benefits State Plan Amendment HOA Demonstration Program (CMS-10216)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10216	HOA Preprint	HOA preprint 11-29-06.doc		No	No	Paper Only
Instruction			HOA SMD112906.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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