Information Collection

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

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 (#9) #9: Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program	Form
CMS-10398 (#9) Application for Section 1915(b)(4) Waiver - Fee For Serv 1915b(4) FFS preprint Template [rev 07-11-2012 by OSORA PRA].doc	Form
#9 1915b4 Supporting Statement [Dec 2014].docx #9 Supporting Statement: Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program	IC Document

IC Title:

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

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
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

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 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	2,240	2,240
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.