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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10444 MEDICAID INCENTIVES FOR PREVENTION OF CHRONIC DISEASES (MIPCD) MINIMUM DATA SET	Form and Instruction
MIPCD_MDS_Format_Transmission_Instructions_07232012_508.docx	Instruction
CMS-10444 Minimum Data Set CA MIPCD_MDS_Data_Elements_CA_07232012_508.docx	Form and Instruction
CMS-10444 Minimum Data Set CT MIPCD_MDS_Data_Elements_CT_07232012_508.docx	Form and Instruction
CMS-10444 Minimum Data Set MT MIPCD_MDS_Data_Elements_MT_07232012_508.docx	Form and Instruction
CMS-10444 Minimum Data Set HI MIPCD_MDS_Data_Elements_HI_07232012_508.docx	Form and Instruction
CMS-10444 Minimum Data Set MN MIPCD_MDS_Data_Elements_MN_07232012_508.docx	Form and Instruction
CMS-10444 Minimum Data Set NH MIPCD_MDS_Data_Elements_NH_07232012_508.docx	Form and Instruction
CMS-10444 Minimum Data Set NV MIPCD_MDS_Data_Elements_NV_07232012_508.docx	Form and Instruction
CMS-10444 Minimum Data Set NY MIPCD_MDS_Data_Elements_NY_07232012_508.docx	Form and Instruction
CMS-10444 Minimum Data Set TX MIPCD_MDS_Data_Elements_TX_07232012_508.docx	Form and Instruction
CMS-10444 Minimum Data Set WI MIPCD_MDS_Data_Elements_WI_07232012_508.docx	Form and Instruction

IC Title:

MEDICAID INCENTIVES FOR PREVENTION OF CHRONIC DISEASES (MIPCD) MINIMUM DATA SET

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

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
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	3,467	3,467
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.