Administrative Cost Forms for MIPCD

Medicaid Incentives for Prevention of Chronic Diseases Evaluation (CMS-10477)

Documents and Forms

Document Name Document Type
Form CMS-10477 Administrative Cost Forms for MIPCD Form and Instruction
CMS-10477 Combined Administrative Cost Form - Informed Consent Attachment_10a_CombinedAdminCostsForm.pdf Form and Instruction
CMS-10477 Yearly Admin Cost Form Attachment_10b_YearlyAdminCostsForm.pdf Form and Instruction
Attachment_10c_AdminCostsFormEmailScr.pdf Admin cost Form Email Script IC Document
Attachment_10d_AdminCostFormEmailAnn.pdf Admin Cost Form Email Solicitation - Script Annual IC Document

Information Collection (IC) Details

IC Title:	Administrative Cost Forms for MIPCD	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10477	Combined Administrative Cost Form - Informed Consent	Attachment_10a_CombinedAdminCostsForm.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10477	Yearly Admin Cost Form	Attachment_10b_YearlyAdminCostsForm.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	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	20	20
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Admin cost Form Email Script	Attachment_10c_AdminCostsFormEmailScr.pdf	10/01/2014
Admin Cost Form Email Solicitation - Script Annual	Attachment_10d_AdminCostFormEmailAnn.pdf	10/01/2014

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