Information Collection

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

IC 46477 under ICR 200706-0938-006 · OMB 0938-1007.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10216 HOA Pre-print Final Alternative Benefits State Plan Amendment HOA Demonstration Program (CMS-10216)	Form
SMD011007.pdf	Instruction
CMS-10216 HOA Pre-print Final HOA_preprintfinal112906.pdf	Form
US Code Title 26A1BVII.pdf US Code Title 26A1BVII	IC Document
30-day FR.pdf 30-day FR notice	IC Document
AARP May 22, 2007 comment.tif Comment	IC Document
Response to Comment from AARP.doc Response to Comment from AARP	IC Document
60-day FR.pdf 60-day FR	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Instruction					No	No	Paper Only
Form	CMS-10216				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	Previously Approved
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
US Code Title 26A1BVII		06/15/2007
30-day FR notice		06/15/2007
Comment		06/15/2007
Response to Comment from AARP		06/15/2007
60-day FR		06/15/2007

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

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