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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.

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Form and Instruction
Form and Instruction
IC Document
IC Document
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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 CMCS
 
New
 
Mandatory
 

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 Children’s Health Insurance Program GenIC _34 - Title-XXI-State-Plan-508final_unlocked_CHIP MC Regs_CLEAN_07-03-2018.docx Yes Yes Fillable Fileable

Health Health Care Services

 

40 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved 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) 5 0 5 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.