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Federal forms, ICRs, and supporting documents

Information Collection

Medicaid Incentives For Prevention Of Chronic Diseases (mipcd) Minimum Data Set

IC 204547 under ICR 201210-0938-008 · OMB 0938-1184.

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

View Information Collection (IC)

MEDICAID INCENTIVES FOR PREVENTION OF CHRONIC DISEASES (MIPCD) MINIMUM DATA SET
 
No New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10444 Minimum Data Set CA MIPCD_MDS_Data_Elements_CA_07232012_508.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10444 Minimum Data Set CT MIPCD_MDS_Data_Elements_CT_07232012_508.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10444 Minimum Data Set MT MIPCD_MDS_Data_Elements_MT_07232012_508.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10444 Minimum Data Set HI MIPCD_MDS_Data_Elements_HI_07232012_508.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10444 Minimum Data Set MN MIPCD_MDS_Data_Elements_MN_07232012_508.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10444 Minimum Data Set NH MIPCD_MDS_Data_Elements_NH_07232012_508.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10444 Minimum Data Set NV MIPCD_MDS_Data_Elements_NV_07232012_508.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10444 Minimum Data Set NY MIPCD_MDS_Data_Elements_NY_07232012_508.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10444 Minimum Data Set TX MIPCD_MDS_Data_Elements_TX_07232012_508.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10444 Minimum Data Set WI MIPCD_MDS_Data_Elements_WI_07232012_508.docx Yes Yes Fillable Fileable
Instruction MIPCD_MDS_Format_Transmission_Instructions_07232012_508.docx No No Paper Only

Health Health Care Services

 

10 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 40 0 0 0 0
Annual IC Time Burden (Hours) 3,467 3,467 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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