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

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.