Information Collection

#34: Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program (CMS-R-211)

IC 214372 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⚠️ Notice: This information collection may be referencing outdated material.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 (#34) (f #34: Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program (CMS-R-211)	Form
CMS-10398 (#34) (f Template for Child Health Plan Under Title XXI of the So GenIC _34 - Title-XXI-State-Plan-508final (3).docx	Form
#34 Supporting Statement [Dec 2014].docx #34 Supporting Statement: Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

#34: Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program (CMS-R-211)

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 (#34) (formerly, CMS-R-211)	Template for Child Health Plan Under Title XXI of the Social Security Act, Childrenâs Health Insurance Program	GenIC _34 - Title-XXI-State-Plan-508final (3).docx		Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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	40	40
Annual IC Time Burden (Hours)	3,200	3,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#34 Supporting Statement: Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Childrenâs Health Insurance Program	#34 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.