Information Collection

Medicaid Enrollees and Disenrolles

IC 199534 under ICR 201110-0990-006 · OMB 0990-0384.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-CHIP Part B_Attachment C_Pretest Report.pdf	Other-survey
CHIP Part A_Attachment C2_Case Studies_Community Enrollment Agencies.pdf	Other-study
CHIP Part A_Attachment C3_Case Studies_Health Care Providers.pdf	Other-study
CHIP Part A_Attachment C1_Case Studies_State Officials.pdf	Other-study
0990-CHIP Part A_Attachment C4_Case Studies_Managed Care and Health Plans.pdf	Other-study

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-survey	0990-CHIP Part B_Attachment C_Pretest Report.pdf	No	No	Paper Only
Other-study	CHIP Part A_Attachment C2_Case Studies_Community Enrollment Agencies.pdf	No	No	Paper Only
Other-study	CHIP Part A_Attachment C3_Case Studies_Health Care Providers.pdf	No	No	Paper Only
Other-study	CHIP Part A_Attachment C1_Case Studies_State Officials.pdf	No	No	Paper Only
Other-study	0990-CHIP Part A_Attachment C4_Case Studies_Managed Care and Health Plans.pdf	No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	0	0	0	0	0	0
Annual IC Time Burden (Hours)	0	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	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.