Information Collection

Administrative Requirements for Section 6071 of the DRA (CMS-10249)

IC 186838 under ICR 200810-0938-007 · OMB 0938-1053.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1053 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10249 Administrative Requirements for Section 6071 of the DRA (CMS-10249) Form and Instruction
Draft Content of MFP-Services File (2).doc Other-Draft Proposed Content for MFP
Draft List of Finder File Data Elements (ver 5) (2) (2).doc Other-Proposed Content for Monthly F
CMS-10249 Operational Protocol Operational Protocol 1-29-07Final.pdf Form and Instruction
CMS-10249 Budget Form Appendix C_ Budget Form (2).xls Form and Instruction
CMS-10249 MFP Demonstration Financial Form Appendix E Forms (2).xls Form and Instruction
CMS-10249 Medical Assistance Expenditures by Type of Service Appendix F 2 27 07 (2).xls Form and Instruction
CMS-10249 6352 MFP Questionnaire 6352 MFP QoL Questionnaire (Version 10).doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Administrative Requirements for Section 6071 of the DRA (CMS-10249)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10249	Operational Protocol	Operational Protocol 1-29-07Final.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10249	Budget Form	Appendix C_ Budget Form (2).xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10249	MFP Demonstration Financial Form	Appendix E Forms (2).xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10249	Medical Assistance Expenditures by Type of Service	Appendix F 2 27 07 (2).xls	Yes	Yes	Fillable Fileable
Other-Draft Proposed Content for MFP Services File			Draft Content of MFP-Services File (2).doc	No	No	Printable Only
Other-Proposed Content for Monthly Finder Files for MFP Grantees			Draft List of Finder File Data Elements (ver 5) (2) (2).doc	No	No	Printable Only
Form	CMS-10249	6352 MFP Questionnaire	6352 MFP QoL Questionnaire (Version 10).doc	No	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 31	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	304	304
Annual IC Time Burden (Hours)	10,394	10,394
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.