Information Collection

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.

⚠️ Notice: This information collection may be referencing outdated material.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 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)	Form
CMS-10398 #34 Template for Child Health Plan Under Title XXI of the So GenIC _34 - Title-XXI-State-Plan-508final_unlocked_clean_5.16.17.docx	Form
GenIC _34 - Title-XXI-State-Plan-508final_unlocked_redlined_5.16.17.docx Template: Track Changes	IC Document
5.16.17_Updated Crosswalk MHPAEA PRA_42017 (05-03-17 OSORA PRA Input).xlsx Template: Crosswalk	IC Document
#34 - Supporting Statement Model Application [rev 05-22-2017 by OSORA PRA].docx GenIC Supporting Statment	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

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)

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

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	Template for Child Health Plan Under Title XXI of the Social Security Act Childrenâs Health Insurance Program	GenIC _34 - Title-XXI-State-Plan-508final_unlocked_clean_5.16.17.docx		Yes	Yes	Fillable Fileable

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: 2

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

Documents for IC

table that charts IC Documents
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

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