Information Collection

Expedited Checklist: Medicaid Eligibility & Enrollment Systems - Advance Planning Document (E&E-APD) (CMS-10385)

IC 197257 under ICR 201110-0938-003 · OMB 0938-1125.

Documents and Forms

Document Name Document Type
Form CMS-10385 Expedited Checklist: Medicaid Eligibility & Enrollment Systems - Advance Planning Document (E&E-APD) (CMS-10385) Form and Instruction
CMS-10385 Expedited Checklist: Medicaid Eligibility & Enrollment I Medicaid Expedited EE APD Checklist [rev 10-06-11].doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Expedited Checklist: Medicaid Eligibility & Enrollment Systems - Advance Planning Document (E&E-APD) (CMS-10385)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 433 45 CFR 95

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10385	Expedited Checklist: Medicaid Eligibility & Enrollment Information System(S) - Advance Planning Document (E&E - APD)	Medicaid Expedited EE APD Checklist [rev 10-06-11].doc		Yes	No	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: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	168	168
Annual IC Time Burden (Hours)	840	840
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.