Information Collection

Collection of Dental Benefit Information

IC 189779 under ICR 201411-0938-011 · OMB 0938-1065.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10291 Collection of Dental Benefit Information	Form
CMS-10291 Insure Kids Now Children’s Dental Benefits Survey IKN Children's Dental Benefits Survey - Electronic - 2014.docx	Form
CMS-10291 Description of Dental Benefits Provided Under Medicaid a Attachment A - description of dental benefits 2014.pdf	Form
Copy of Children's Dental Benefits Survey Crosswalk 2.pdf Crossswalk - Benefits Survey	IC Document
Copy of Attachment A Description of Dental Benefits Crosswalk 2.pdf Crosswalk - Description of Dental Benefits Provided Under Medicaid and CHIP	IC Document

IC Title:

Collection of Dental Benefit Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-10291	Insure Kids Now Childrenâs Dental Benefits Survey	IKN Children's Dental Benefits Survey - Electronic - 2014.docx		Yes	Yes	Fillable Printable
Form	CMS-10291	Description of Dental Benefits Provided Under Medicaid and CHIP	Attachment A - description of dental benefits 2014.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicaid Drug Rebate Program

FR Citation: 78 FR 15744

Number of Respondents: 51

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	Previously Approved
Annual Number of Responses for this IC	51	0	51
Annual IC Time Burden (Hours)	1,250	-280	1,530
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crossswalk - Benefits Survey	Copy of Children's Dental Benefits Survey Crosswalk 2.pdf	12/02/2014
Crosswalk - Description of Dental Benefits Provided Under Medicaid and CHIP	Copy of Attachment A Description of Dental Benefits Crosswalk 2.pdf	12/02/2014

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