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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.