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GenIC #34 (Extension w/o change): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the SSA, State CHIP

IC 229697 under ICR 201712-0938-019 · OMB 0938-1148.

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GenIC #34 (Extension w/o change): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the SSA, State CHIP
 
New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10398 #34 Title XXI State Plan Template 34 - Title-XXI-State-Plan.docx Yes Yes Fillable Fileable

Health Health Care Services

 

40 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 40 0 40 0 0 0
Annual IC Time Burden (Hours) 3,200 0 3,200 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
#34 - Supporting Statement 34 - Supporting Statement Model Application Template and Instructions for State Child Health Plan.docx 01/09/2018
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