Information Collection

State Balancing Incentive Payments Program (BIPP) Application (CMS-10411)

IC 199182 under ICR 201109-0938-002 · OMB 0938-1145.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1145 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10411 State Balancing Incentive Payments Program (BIPP) Application (CMS-10411) Form and Instruction
CMS-10411 State Balancing Incentive Payments Program (BIPP) Applic BIPP App_Clean_083111 [rev 09-06-11].doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State Balancing Incentive Payments Program (BIPP) Application (CMS-10411)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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-10411	State Balancing Incentive Payments Program (BIPP) Application	BIPP App_Clean_083111 [rev 09-06-11].doc		Yes	Yes	Fillable Printable

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: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	2,240	2,240
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.