Collection of Dental Provider Information

State Collection and Reporting of Dental Provider and Benefit Package Information on the Insure Kids Now! Website and Hotline (CMS-10291)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1065 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10291 Collection of Dental Provider Information Form and Instruction
CMS-10291 Provider Data Submission Technical Information Insure Kids Now Technical Guidance_September 2017.pdf Form and Instruction
IKN PRA Crosswalk508.pdf Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Collection of Dental Provider Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10291	Provider Data Submission Technical Information	Insure Kids Now Technical Guidance_September 2017.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	204	0	204
Annual IC Time Burden (Hours)	10,506	918	9,588
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	IKN PRA Crosswalk508.pdf	01/19/2018

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