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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.