Information Collection

State Plan preprints to Implement Sections of the Deficit Reduction Act of 2006 and Third-party Disclosure for Non-emergencies

IC 180500 under ICR 200910-0938-013 · OMB 0938-0993.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10190 State Plan preprints to Implement Sections of the Deficit Reduction Act of 2006 and Third-party Disclosure for Non-emergencies	Form and Instruction
CMS-10190 6043 Costsharing Preprint PRA 508ed_DRA Preprint 6043CostsharingPreprint revised Att 4 18-H clean (2).pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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-10190	6043 Costsharing Preprint	PRA 508ed_DRA Preprint 6043CostsharingPreprint revised Att 4 18-H clean (2).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: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	667	667
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.