Information Collection

Medicaid and State Children's Health Insurance Plan (SCHIP) Managed Care

IC 43679 under ICR 200711-0938-005 · OMB 0938-0994.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0994 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10178 Medicaid and State Children's Health Insurance Plan (SCHIP) Managed Care Form and Instruction
CMS-10178 CAP SHO Letter CAP SHO Letter FINAL to OMB 090407.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicaid and State Children's Health Insurance Plan (SCHIP) Managed Care	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10178	CAP SHO Letter	CAP SHO Letter FINAL to OMB 090407.doc		No	No	Fillable Fileable

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: 10 %

	Approved	Previously Approved
Annual Number of Responses for this IC	23,400	23,400
Annual IC Time Burden (Hours)	23,400	23,400
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.