Information Collection

Collection of Dental Provider Information

IC 189778 under ICR 201111-0938-006 · OMB 0938-1065.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1065 can be found here:

Documents and Forms

Document Name Document Type
Provider Info - Disclosure Statement.doc Other-Provider Information - Disclos
CMS-10291 Insure Kids Now (Provider Data Submission Technical Info InsureKidsNow-Technical-Document 201102 FINAL.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Collection of Dental Provider Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Other-Provider Information - Disclosure Statement			Provider Info - Disclosure Statement.doc		Yes	Yes	Printable Only
Form and Instruction	CMS-10291	Insure Kids Now (Provider Data Submission Technical Information)	InsureKidsNow-Technical-Document 201102 FINAL.docx		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	204	204
Annual IC Time Burden (Hours)	8,160	8,160
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.