Information Collection

Optional Dental-only Supplemental Coverage SPA Template (CMS-10289)

IC 191028 under ICR 201011-0938-001 · OMB 0938-1075.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-100289 Optional Dental-only Supplemental Coverage SPA Template (CMS-10289)	Form and Instruction
CMS-100289 Addendum on Supplemental Dental Benefits Under Title XXI Draft CHIP SPA Dental Template (2)final.docx	Form and Instruction
Draft CHIP SPA Dental Template (2)-TRC.docx Addendum on Supplemental Dental Benefits Under Title XXI	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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-100289	Addendum on Supplemental Dental Benefits Under Title XXI	Draft CHIP SPA Dental Template (2)final.docx		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	51	51
Annual IC Time Burden (Hours)	1,020	1,020
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Addendum on Supplemental Dental Benefits Under Title XXI	Draft CHIP SPA Dental Template (2)-TRC.docx	10/19/2010

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