Provider-Preventable Conditions (GenIC #32) and DRA 6062 (GenIC #33)

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10398 (#32) Provider-Preventable Conditions (GenIC #32) and DRA 6062 (GenIC #33) Form
Instructions - Provider-Preventable Conditions (#32) [rev 7-17-2014 at 2_00 pm by OSORA PRA].docx Instruction
CMS-10398 (#32) Preprint - Provider-Preventable Conditions for Non-Payme Pre-Print - Provider-Preventable Conditions (#32) [rev 7-17-2014 at 2_00 pm by OSORA PRA].docx Form
CMS-10398 (#33) DRA 6062 (Preprint Attachments 2.2-A and 2.6-A) Preprint - DRA 6062 (#33) [rev 7-17-2014 by OSORA PRA].docx Form
Supporting Statement - Provider-Preventable Conditions (#32) [rev 7-17-2014 at 1_30 pm by OSORA PRA].docx Supporting Statement - Provider-Preventable Conditions (GenIC #32) IC Document
DRA 6062 Supporting Statement [rev 7-18-2014 by OSORA PRA].docx Supporting Statement - DRA 6062 (GenIC #33) IC Document

Information Collection (IC) Details

IC Title:	Provider-Preventable Conditions (GenIC #32) and DRA 6062 (GenIC #33)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 (#32)	Preprint - Provider-Preventable Conditions for Non-Payment under Section 4.19	Pre-Print - Provider-Preventable Conditions (#32) [rev 7-17-2014 at 2_00 pm by OSORA PRA].docx	Yes	Yes	Fillable Printable
Instruction			Instructions - Provider-Preventable Conditions (#32) [rev 7-17-2014 at 2_00 pm by OSORA PRA].docx	No		Printable Only
Form	CMS-10398 (#33)	DRA 6062 (Preprint Attachments 2.2-A and 2.6-A)	Preprint - DRA 6062 (#33) [rev 7-17-2014 by OSORA PRA].docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 42	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	42	42
Annual IC Time Burden (Hours)	3,278	3,278
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement - Provider-Preventable Conditions (GenIC #32)	Supporting Statement - Provider-Preventable Conditions (#32) [rev 7-17-2014 at 1_30 pm by OSORA PRA].docx	07/18/2014
Supporting Statement - DRA 6062 (GenIC #33)	DRA 6062 Supporting Statement [rev 7-18-2014 by OSORA PRA].docx	07/18/2014

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