Collection of Dental Provider Information

CHIPRA 2009, Dental Provider and Benefit Information Posted on Insure Kids Now! Website (CMS-10291)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1065 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10291 Collection of Dental Provider Information Form and Instruction
CMS-10291 Provider Data Submission Technical Information Insure Kids Now Technical Guidance Ver 2.9 December 2013.docx Form and Instruction
Copy of IKN Technical Guidance Crosswalk 07252014.pdf Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Collection of Dental Provider Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10291	Provider Data Submission Technical Information	Insure Kids Now Technical Guidance Ver 2.9 December 2013.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	204	0	204
Annual IC Time Burden (Hours)	9,588	1,428	8,160
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Copy of IKN Technical Guidance Crosswalk 07252014.pdf	12/02/2014

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