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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.