Information Collection

Collection of Dental Provider Information

IC 189778 under ICR 201001-0938-006 · OMB 0938-1065.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1065 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10291 Benefit Template Collection of Dental Provider Information	Form
InsureKidsNow-Technical-Document Att B.doc	Instruction
CMS-10291 Benefit Template Benefit template_A~1.doc	Form
CHIPRA Dental SHO Final 100709revised.pdf SHO Letter	IC Document

IC Title:

Collection of Dental Provider Information

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
Instruction					Yes	Yes	Printable Only
Form	CMS-10291				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	Previously Approved
Annual Number of Responses for this IC	204	204
Annual IC Time Burden (Hours)	8,160	8,160
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SHO Letter		12/04/2009

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

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