Information Collection

GenIC # 43 - Section 223 Demonstration Programs to Improve Community Mental Health Services (CMS-10398)

IC 219037 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⚠️ Notice: This information collection may be referencing outdated material.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 (#43) GenIC # 43 - Section 223 Demonstration Programs to Improve Community Mental Health Services (CMS-10398)	Form
CCBHC Cost Report Instructions 508c 11 10 15.pdf	Instruction
CMS-10398 (#43) CCMHC Cost Report CCBHC 508 Cost Report 11.10.15.xlsx	Form
CMS-10398 (#43) State Demonstration Proposal Application and Guidance State Demonstration Proposal Application and Guidance_100515f_revised 101515_submitted (3).pdf	Form and Instruction
CCBHC Cost Reporting - Combined Comment and Response to Public Comments [rev 11-16-2015 by OSORA PRA].docx Cost Report - Public Comment and CMS Response	IC Document
Crosswalk - Cost report and instructions revisions 11.10.15.xlsx Cost Report - Crosswalk	IC Document
GenIC 43 Supporting Statement - Section 223 Demonstration Programs [rev 11-19-2015 by OSORA PRA].docx Supporting Statement	IC Document

IC Title:

GenIC # 43 - Section 223 Demonstration Programs to Improve Community Mental Health Services (CMS-10398)

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 (#43)	CCMHC Cost Report	CCBHC 508 Cost Report 11.10.15.xlsx	Yes	Yes	Fillable Printable
Instruction			CCBHC Cost Report Instructions 508c 11 10 15.pdf	No		Printable Only
Form and Instruction	CMS-10398 (#43)	State Demonstration Proposal Application and Guidance	State Demonstration Proposal Application and Guidance_100515f_revised 101515_submitted (3).pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 97

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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	121	121
Annual IC Time Burden (Hours)	7,490	7,490
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cost Report - Public Comment and CMS Response	CCBHC Cost Reporting - Combined Comment and Response to Public Comments [rev 11-16-2015 by OSORA PRA].docx	11/19/2015
Cost Report - Crosswalk	Crosswalk - Cost report and instructions revisions 11.10.15.xlsx	11/19/2015
Supporting Statement	GenIC 43 Supporting Statement - Section 223 Demonstration Programs [rev 11-19-2015 by OSORA PRA].docx	11/19/2015

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