1932 State Plan Amendment Template, State Plan Requirements, and Supporting Regulations in 42 CFR 438.50

1932 State Plan Amendment Template, State Plan Requirements, and Supporting Regulations in 42 CFR 438.50 (CMS-10120)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0933 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10120 1932 State Plan Amendment Template, State Plan Requirements, and Supporting Regulations in 42 CFR 438.50 Form and Instruction
CMS-10120 1932 State Plan Amendment Template CMS-10120 SPA-051004.doc Form and Instruction

Information Collection (IC) Details

IC Title:	1932 State Plan Amendment Template, State Plan Requirements, and Supporting Regulations in 42 CFR 438.50	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10120	1932 State Plan Amendment Template	CMS-10120 SPA-051004.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	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	10	10
Annual IC Time Burden (Hours)	100	100
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.