Information Collection

State Plan preprints to implement Sections of the Deficit Reduction Act of 2006 and Third-party Disclosure for Non-emergencies (CMS-10190)

IC 43678 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 (CMS-10190)	Form and Instruction
CMS-10190 DRA 6041 Costsharing Preprint DRA 6041CostsharingPreprint revised Att 4 18-F clean.doc	Form and Instruction
CMS-10190 DRA 6042 costsharing preprint DRA 6042costsharingpreprint revised Att 4 18-G clean.doc	Form and Instruction
CMS-10190 nem3 1d 508ed_nem3 1d.pdf	Form and Instruction
CMS-10190 Non-Emergency Medical Transportation preprint 508ed_nemtbrokerpreprintBespa6-5-09.pdf	Form and Instruction
CMS-10190 6044 Benchmark Preprint PRA 508ed_Benchmark Preprint Sec 3 1-C version4 7-21- 09.pdf	Form and Instruction
PRA Summary of Modifications to DRA Preprints.docx PRA Summary of Modifications to DRA Preprints	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 1396

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10190	DRA 6041 Costsharing Preprint	DRA 6041CostsharingPreprint revised Att 4 18-F clean.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10190	DRA 6042 costsharing preprint	DRA 6042costsharingpreprint revised Att 4 18-G clean.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10190	nem3 1d	508ed_nem3 1d.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10190	Non-Emergency Medical Transportation preprint	508ed_nemtbrokerpreprintBespa6-5-09.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10190	6044 Benchmark Preprint	PRA 508ed_Benchmark Preprint Sec 3 1-C version4 7-21- 09.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16

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 Agency Discretion	Previously Approved
Annual Number of Responses for this IC	16	-40	56
Annual IC Time Burden (Hours)	32	-24	56
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PRA Summary of Modifications to DRA Preprints	PRA Summary of Modifications to DRA Preprints.docx	10/23/2009

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.