Model Application Template for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program, & Model Application Template & Instructions

Model Application Template for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program, & Model Application Template & Instructions (CMS-R-211)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0707 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-R-211 Model Application Template for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program, & Model Application Template & Instructions Form and Instruction
CMS-R-211 Template for Child Health Plan Under Title XXI of the SS CMS-R-211 Template (rev 05_24_11) .pdf Form and Instruction
Crosswalk of changes for OMB.doc CMS-R-211 Crosswalk IC Document
Instructions-Template final 508.pdf CMS-R-211 Template with Highlighted Changes IC Document

Information Collection (IC) Details

IC Title:	Model Application Template for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program, & Model Application Template & Instructions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 457.60

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-211	Template for Child Health Plan Under Title XXI of the SSA Children's Health Insurance Program	CMS-R-211 Template (rev 05_24_11) .pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 54	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	40	40
Annual IC Time Burden (Hours)	3,200	3,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-R-211 Crosswalk	Crosswalk of changes for OMB.doc	05/24/2011
CMS-R-211 Template with Highlighted Changes	Instructions-Template final 508.pdf	05/24/2011

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