OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Model Application Template for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program, & Model Application Template & Instructions

IC 8347 under ICR 201209-0938-006 · OMB 0938-0707.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Model Application Template for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program, & Model Application Template & Instructions
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 457.60

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-R-211 Template for Child Health Plan Under Title XXI of the Social Security Act Children's Health Insurance Program Title XXI State Plan revised PRA 9-19-12.docx Yes Yes Fillable Printable

Health Health Care Services

 

54 0
   
State, Local, and Tribal Governments
 
   100 %

  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 40 0 0 0 0 40
Annual IC Time Burden (Hours) 3,200 0 0 0 0 3,200
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CMS-R-211 - Crosswalk (nonsubstantial changes) Crosswalk of nonsub template changes for CMS-R-211.doc 09/23/2012
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.