Information Collection

Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template

IC 214452 under ICR 201412-0938-010 · OMB 0938-1268.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1268 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10536 Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template	Form and Instruction
CMS-10536 Medicaid Eligibility and Enrollment (EE) Implementation Medicaid_EE_IAPD_Template_2015_02_18.pdf	Form and Instruction

IC Title:

Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template

Agency IC Tracking Number:

Is this a Common Form? No

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10536	Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template	Medicaid_EE_IAPD_Template_2015_02_18.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

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 New Statute
Annual Number of Responses for this IC	168	168
Annual IC Time Burden (Hours)	2,688	2,688
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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