Information Collection

Medicaid Savings Program Protection from Medicaid Estate Recovery -- State Plan Preprint Under Title 19 (CMS-10314)

IC 194671 under ICR 201009-0938-011 · OMB 0938-1108.

Documents and Forms

Document Name Document Type
Form CMS-10314 Medicaid Savings Program Protection from Medicaid Estate Recovery -- State Plan Preprint Under Title 19 (CMS-10314) Form
CMS-10314 Medicare Savings Program Protection from Medicaid Estate CMS-10314 PRAPreprint.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicaid Savings Program Protection from Medicaid Estate Recovery -- State Plan Preprint Under Title 19 (CMS-10314)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10314	Medicare Savings Program Protection from Medicaid Estate Recovery -- State Plan Preprint Under Title XIX of the Social Security Act	CMS-10314 PRAPreprint.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 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	102	102
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.