Initial Application

Medicaid and CHIP Program (MACPro)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1188 can be found here:

Documents and Forms

Document Name Document Type
IG_I1_State Information_R1_Draft_11-30-12.docx Instruction
IG_I4 - CHIP Amendment Submission_R1 Final_11-30-12.docx Instruction
IG_I2 - Medicaid State Plan-Specific Submission Data_R1_Draft_11-30-12.docx Instruction
IG_I5 - Public Comment_R1_Draft_11-30-12.docx Instruction
IG_I6 - Tribal Input_R1_Draft_11-30-12.docx Instruction
CMS-10434 Initial Application Initial Application Form.pdf Form and Instruction
Initial Application Transcript.pdf Initial Application - Webinar Transcript IC Document

Information Collection (IC) Details

IC Title:	Initial Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 430.12

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			IG_I1_State Information_R1_Draft_11-30-12.docx	Yes	No	Printable Only
Form and Instruction	CMS-10434	Initial Application	Initial Application Form.pdf	Yes	Yes	Fillable Fileable
Instruction			IG_I4 - CHIP Amendment Submission_R1 Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_I2 - Medicaid State Plan-Specific Submission Data_R1_Draft_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_I5 - Public Comment_R1_Draft_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_I6 - Tribal Input_R1_Draft_11-30-12.docx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	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	56	56
Annual IC Time Burden (Hours)	280	280
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Initial Application - Webinar Transcript	Initial Application Transcript.pdf	01/08/2013

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