Information Collection

CHIPRA State Option Pre-print to include Pregnant Women (CMS-10284)

IC 190366 under ICR 200908-0938-008 · OMB 0938-1068.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10284 CHIPRA State Option Pre-print to include Pregnant Women (CMS-10284)	Form
CMS-10284 Addendum to State Health Plan Describing Coverage of Pre CMS-10284 Pregnant Women Preprint.pdf	Form

IC Title:

Agency IC Tracking Number:

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
Form	CMS-10284	Addendum to State Health Plan Describing Coverage of Pregnant Women	CMS-10284 Pregnant Women Preprint.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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
	Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	80	0	0	0	0	0
Annual IC Time Burden (Hours)	3,200	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	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.