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

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.