Information Collection

Collection of Dental Benefit Information

IC 189779 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
CMS-10291[1].InsureKidsNow-Technical-Document-6-19-09 Instruction
CMS-10291.Draft Benefit Template.pdf Other-CMS-10291.Draft Benefit Templa
CMS-10291.guidance.pdf Other-CMS-10291.Guidance

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Collection of Dental Benefit Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-CMS-10291.Draft Benefit Template	CMS-10291.Draft Benefit Template.pdf	Yes	Yes	Fillable Fileable
Other-CMS-10291.Guidance	CMS-10291.guidance.pdf	Yes	Yes	Fillable Fileable
Instruction	CMS-10291[1].InsureKidsNow-Technical-Document-6-19-09	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	Previously Approved
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

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.