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#9: Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program

IC 214290 under ICR 201410-0938-016 · OMB 0938-1148.

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#9: Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program
 
New
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10398 (#9) Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program 1915b(4) FFS preprint Template [rev 07-11-2012 by OSORA PRA].doc Yes Yes Fillable Printable

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Requested 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 56 0 56 0 0 0
Annual IC Time Burden (Hours) 2,240 0 2,240 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
#9 Supporting Statement: Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program #9 1915b4 Supporting Statement [Dec 2014].docx 12/22/2014
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.