Information Collection

Collection of Dental Provider Information

IC 189778 under ICR 200906-0938-016 · OMB 0938-1065.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1065 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10291.Draft Benefit Template.pdf	Other-CMS-10291.Draft Benefit Templa
CMS-10291[1].InsureKidsNow-Technical-Document-6-19-09	Instruction
CMS-10291.guidance.pdf	Other-Guidance

IC Title:

Collection of Dental Provider Information

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	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-CMS-10291.Draft Benefit Template	CMS-10291.Draft Benefit Template.pdf	Yes	Yes	Fillable Fileable
Instruction	CMS-10291[1].InsureKidsNow-Technical-Document-6-19-09	Yes	Yes	Fillable Fileable
Other-Guidance	CMS-10291.guidance.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

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 New Statute
Annual Number of Responses for this IC	204	204
Annual IC Time Burden (Hours)	8,160	8,160
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.