Information Collection

Collection of Dental Benefit Information

IC 189779 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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10291 Collection of Dental Benefit Information	Form
CMS-10291 Children's Dental Benefits Survey Copy of Dental Benefits - Survey --- rev 11-22-11.xlsx	Form
CMS-10291 Description of Dental Benefits Provided Under Medicaid a Dental Benefits - Description [rev 11-22-11].doc	Form
OMB Crosswalk (2).doc Crosswalk - Dental Benefit Survey	IC Document

IC Title:

Collection of Dental Benefit 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
Form	CMS-10291	Children's Dental Benefits Survey	Copy of Dental Benefits - Survey --- rev 11-22-11.xlsx		Yes	Yes	Fillable Printable
Form	CMS-10291	Description of Dental Benefits Provided Under Medicaid and the Children's Health Insurance Program (CHIP)	Dental Benefits - Description [rev 11-22-11].doc		Yes	Yes	Fillable Printable

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	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	51	0	51
Annual IC Time Burden (Hours)	1,530	510	1,020
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk - Dental Benefit Survey	OMB Crosswalk (2).doc	11/04/2011

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