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GenIC #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 (Formerly CMS-R-211)

IC 226959 under ICR 201410-0938-016 · OMB 0938-1148.

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GenIC #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 (Formerly CMS-R-211)
 
New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10398 #34 Template for Child Health Plan Under Title XXI of the Social Security Act Children’s Health Insurance Program GenIC _34 - Title-XXI-State-Plan-508final_unlocked_clean_5.16.17.docx Yes Yes Fillable Fileable

Health Health Care Services

 

2 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved 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 2 0 2 0 0 0
Annual IC Time Burden (Hours) 160 0 160 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Template: Track Changes GenIC _34 - Title-XXI-State-Plan-508final_unlocked_redlined_5.16.17.docx 05/22/2017
Template: Crosswalk 5.16.17_Updated Crosswalk MHPAEA PRA_42017 (05-03-17 OSORA PRA Input).xlsx 05/22/2017
GenIC Supporting Statment #34 - Supporting Statement Model Application [rev 05-22-2017 by OSORA PRA].docx 05/22/2017
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