Information Collection

Option to Cover Certain Children and Pregnant Women Lawfully Residing in the U.S. State Plan Amendment Template (CMS-10299)

IC 191979 under ICR 201002-0938-004 · OMB 0938-1082.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1082 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10299 Option to Cover Certain Children and Pregnant Women Lawfully Residing in the U.S. State Plan Amendment Template (CMS-10299)	Form and Instruction
CMS-10299 Draft CHIP State Plan for Section 214 Option Draft CHIP State Plan for Section 214 Option.doc	Form and Instruction
CMS-10299 pre-print 5 year bar waiver CMS-10299 pre-print 5 year bar waiver.doc	Form and Instruction

IC Title:

Option to Cover Certain Children and Pregnant Women Lawfully Residing in the U.S. State Plan Amendment Template (CMS-10299)

Agency IC Tracking Number:

Is this a Common Form?

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-10299	Draft CHIP State Plan for Section 214 Option	Draft CHIP State Plan for Section 214 Option.doc		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10299	pre-print 5 year bar waiver	CMS-10299 pre-print 5 year bar waiver.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)	51	51
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.