Information Collection

State Plan Preprint to Implement Required Dental Benefits Pursuant of CHIPRA 2009 (CMS-10288)

IC 191056 under ICR 200910-0938-007 · OMB 0938-1076.

Documents and Forms

Document Name Document Type
Form CMS-10288 State Plan Preprint to Implement Required Dental Benefits Pursuant of CHIPRA 2009 (CMS-10288) Form and Instruction
CMS-10288 SPA Template Addendum on Dental Benefits Under Title XXI CMS-10288 required dental benefits template with disclosure 9-25-09.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State Plan Preprint to Implement Required Dental Benefits Pursuant of CHIPRA 2009 (CMS-10288)	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10288	SPA Template Addendum on Dental Benefits Under Title XXI	CMS-10288 required dental benefits template with disclosure 9-25-09.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 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	1,530	1,530
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.