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
Form CMS-10251 State Plan Preprint for Integrated Care Programs State Plan preprint for Integrated Medicare and Medicaid Programs (CMS-10251)	Form
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					No	No	Paper Only
Form	CMS-10251				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		02/19/2008

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].