Information Collection

State Plan preprint for Integrated Medicare and Medicaid Programs (CMS-10251)

IC 184093 under ICR 200803-0938-004 · OMB 0938-1047.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1047 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Integrated Care Preprint Instructions 1-16-08 revisions.doc	Instruction
CMS-10251 State Plan Preprint for Integrated Care Programs Integrated Care Preprint 1-16-08 clean copy.doc	Form
CMS-10251 SMD on IC Preprint.doc SMD Letter	IC Document

IC Title:

State Plan preprint for Integrated Medicare and Medicaid Programs (CMS-10251)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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			Integrated Care Preprint Instructions 1-16-08 revisions.doc		No	No	Paper Only
Form	CMS-10251	State Plan Preprint for Integrated Care Programs	Integrated Care Preprint 1-16-08 clean copy.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	600	600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SMD Letter	CMS-10251 SMD on IC Preprint.doc	02/19/2008

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