Information Collection

PACE State Plan Option Preprint (CMS-10227)

IC 181912 under ICR 200709-0938-001 · OMB 0938-1027.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1027 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10227 PACE State Plan Option Preprint (CMS-10227)	Form
SMDL-11-09-00.tif	Instruction
CMS-10227 PACE State Plan Option Preprint CMS-10227 SPA PACE PREPRINT.doc	Form

IC Title:

PACE State Plan Option Preprint (CMS-10227)

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-10227	PACE State Plan Option Preprint	CMS-10227 SPA PACE PREPRINT.doc		No	No	Fillable Printable
Instruction			SMDL-11-09-00.tif		No	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 36

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	36	36
Annual IC Time Burden (Hours)	240	240
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.