Information Collection

Medicaid State Plan Preprint for Use by States When Implementing Section 6401, the Provider Screening and Other Enrollment Requirements Under Medicare, Medicaid and CHIP

IC 199726 under ICR 201110-0938-004 · OMB 0938-1151.

Documents and Forms

Document Name Document Type
Form CMS-10402 Medicaid State Plan Preprint for Use by States When Implementing Section 6401, the Provider Screening and Other Enrollment Requirements Under Medicare, Medicaid and CHIP Form
CMS-10402 Provider Screening and Enrollment Guidance Provider Screening and Enrollment Guidance [rev 2011-29-11 at 5_00 pm].docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicaid State Plan Preprint for Use by States When Implementing Section 6401, the Provider Screening and Other Enrollment Requirements Under Medicare, Medicaid and CHIP	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10402	Provider Screening and Enrollment Guidance	Provider Screening and Enrollment Guidance [rev 2011-29-11 at 5_00 pm].docx		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	Program Change Due to New Statute
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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