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Federal forms, ICRs, and supporting documents

Information Collection

GenIc #9 (Extension w/o change): Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program

IC 229608 under ICR 201712-0938-019 · OMB 0938-1148.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
IC Document
Information Collection (IC) Details

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GenIc #9 (Extension w/o change): Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program
 
New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10398 #9 Application for Section 1915(b)(4) Waiver - Fee For Service Selective Contracting Program 1915b(4) FFS preprint Template [rev 07-11-2012 by OSORA PRA].doc Yes Yes Fillable Fileable

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Requested 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 56 0 56 0 0 0
Annual IC Time Burden (Hours) 2,240 0 2,240 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
#9 - Supporting Statement 9-Supporting Statement Application for Section 1915(b)(4) Waiver.docx 12/29/2017
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.