Information Collection

Additional State Plan Option for Providing Premium Assistance State Plan Templates under Title XIX and XXI (CMS-10300)

IC 191978 under ICR 201002-0938-003 · OMB 0938-1084.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10300 Additional State Plan Option for Providing Premium Assistance State Plan Templates under Title XIX and XXI (CMS-10300)	Form and Instruction
CMS-10300 Additional State Plan Option for Providing Premium Assis CMS-10300 XXI Template1 revised 3-4-10.doc	Form and Instruction
CMS-10300 Additional State Plan Option for Providing Premium Assis CMS-10300 XIX Template2 revised 3-4-10 per OMB.doc	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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-10300	Additional State Plan Option for Providing Premium Assistance CHIP Mediciad Template	CMS-10300 XIX Template2 revised 3-4-10 per OMB.doc		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10300	Additional State Plan Option for Providing Premium Assistance CHIP SPA Template	CMS-10300 XXI Template1 revised 3-4-10.doc		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	Program Change Due to New Statute
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	255	255
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.