Information Collection

GenIC #34 (Revision): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program

IC 232065 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⚠️ Notice: This information collection may be referencing outdated material.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 #34 GenIC #34 (Revision): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program	Form and Instruction
CMS-10398 #34 Template for Child Health Plan Under Title XXI of The So GenIC _34 - Title-XXI-State-Plan-508final_unlocked_CHIP MC Regs_CLEAN_07-03-2018.docx	Form and Instruction
#34 - Generic Supporting Statement (rev 07-06-2018 by OSORA PRA) CLEAN.docx Supporting Statement	IC Document
#34 - Crosswalk CHIP Managed Care Regs PRA_June 2018.xlsx Crosswalk: State Plan Template	IC Document
GenIC _34 - Title-XXI-State-Plan-508final_unlocked_CHIP MC Regs_Track Changes_07-05-2018.docx Track Change: State Plan Template	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC #34 (Revision): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program

Agency IC Tracking Number:

CMCS

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10398 #34	Template for Child Health Plan Under Title XXI of The Social Security Act Childrenâs Health Insurance Program	GenIC _34 - Title-XXI-State-Plan-508final_unlocked_CHIP MC Regs_CLEAN_07-03-2018.docx		Yes	Yes	Fillable Fileable

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: 40

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
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement	#34 - Generic Supporting Statement (rev 07-06-2018 by OSORA PRA) CLEAN.docx	07/06/2018
Crosswalk: State Plan Template	#34 - Crosswalk CHIP Managed Care Regs PRA_June 2018.xlsx	07/06/2018
Track Change: State Plan Template	GenIC _34 - Title-XXI-State-Plan-508final_unlocked_CHIP MC Regs_Track Changes_07-05-2018.docx	07/06/2018

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