Medicaid Enrollees and Disenrolles

CHIPRA_ Children Health Insurance

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Medicaid Enrollees and Disenrolles	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:

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 %

	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

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.