Information Collection

State Plan preprint for Integrated Medicare and Medicaid Programs (CMS-10251)

IC 184093 under ICR 201105-0938-011 · OMB 0938-1047.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Integrated Care Preprint Instructions 1-16-08 revisions.doc	Instruction
CMS-10251 State Plan Preprint for Integrated Care Programs Integrated Care Preprint 1-16-08 clean copy.doc	Form
CMS-10251 SMD on IC Preprint.doc SMD Letter	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Instruction			Integrated Care Preprint Instructions 1-16-08 revisions.doc		No	No	Paper Only
Form	CMS-10251	State Plan Preprint for Integrated Care Programs	Integrated Care Preprint 1-16-08 clean copy.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10	-20	30
Annual IC Time Burden (Hours)	200	-400	600
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SMD Letter	CMS-10251 SMD on IC Preprint.doc	02/19/2008

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