Information Collection

Model Application Template for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program, & Model Application Template & Instructions

IC 8347 under ICR 200805-0938-010 · OMB 0938-0707.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0707 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-211 Model Application Template for State Children's Health Insurance Program Model Application Template for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program, & Model Application Template & Instructions	Form and Instruction
CMS-R-211 Model Application Template for State Children's Health I Instructions.doc	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Model Application Template for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program, & Model Application Template & Instructions

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
Form and Instruction	CMS-R-211				Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	3,200	3,200
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].