Information Collection

Optional Dental-only Supplemental Coverage SPA Template (CMS-10289)

IC 191028 under ICR 200910-0938-004 · OMB 0938-1075.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1075 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10289 Optional Dental-only Supplemental Coverage SPA Template (CMS-10289)	Form and Instruction
CMS-10289 Supplemental Dental Benefits Under Title XXI CMS-10289 Supplemental Dental template with disclosure 09-25-09.docx	Form and Instruction

IC Title:

Optional Dental-only Supplemental Coverage SPA Template (CMS-10289)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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-10289	Supplemental Dental Benefits Under Title XXI	CMS-10289 Supplemental Dental template with disclosure 09-25-09.docx		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	51	51
Annual IC Time Burden (Hours)	1,020	1,020
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.