Information Collection

GenIC #51 (Extension w/o change): Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions

IC 229739 under ICR 201712-0938-019 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 #51 Application Certification Statement - Section 1115(a) Extension GenIC #51 (Extension w/o change): Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions	Form and Instruction
Form CMS-10398 #51 1115(e) Extension State Certification GenIC #51 (Extension w/o change): Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions	Form and Instruction
Form CMS-10398 #51 1115(f) Extension State Certification GenIC #51 (Extension w/o change): Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions	Form and Instruction
Form CMS-10398 #51 Extension With Changes Template GenIC #51 (Extension w/o change): Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions	Form and Instruction
CIB07242015-Fast-Track (1).pdf	Instruction
CMS-10398 #51 Application Certification Statement - Section 1115(a) Ex 51 - 1115a extension state certification.docx	Form and Instruction
CMS-10398 #51 1115(e) Extension State Certification 51 - 1115e extension state certification.docx	Form and Instruction
CMS-10398 #51 1115(f) Extension State Certification 51 - 1115f extension state certification.docx	Form and Instruction
CMS-10398 #51 Extension With Changes Template #51 - Extension with Changes Template_09-13-2016.doc	Form and Instruction
51 - Supporting Statement Fast Track for Section 1115 Medicaid and CHIP Demonstration Extensions_11 13 17 rev.docx #51 - Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC #51 (Extension w/o change): Fast Track Federal Review Process for Section 1115 Medicaid and CHIP Demonstration Extensions

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10398 #51	Application Certification Statement - Section 1115(a) Extension	51 - 1115a extension state certification.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #51	1115(e) Extension State Certification	51 - 1115e extension state certification.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #51	1115(f) Extension State Certification	51 - 1115f extension state certification.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #51	Extension With Changes Template	#51 - Extension with Changes Template_09-13-2016.doc	Yes	Yes	Fillable Fileable
Instruction			CIB07242015-Fast-Track (1).pdf	No		Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3

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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3	3
Annual IC Time Burden (Hours)	450	450
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#51 - Supporting Statement	51 - Supporting Statement Fast Track for Section 1115 Medicaid and CHIP Demonstration Extensions_11 13 17 rev.docx	01/12/2018

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