Information Collection

Collection of Dental Benefit Information

IC 189779 under ICR 201801-0938-006 · OMB 0938-1065.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10291 Collection of Dental Benefit Information	Form
Summary of Benefits Page - PRA Text.png	Other-Screenshot: Summary of Benefit
CMS-10291 Insure Kids Now Children’s Dental Benefits Survey IKN Children's Dental Benefits Survey - 508.pdf	Form
IKN PRA Crosswalk508.pdf Crossswalk	IC Document

IC Title:

Collection of Dental Benefit Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	CMS-10291	Insure Kids Now Childrenâs Dental Benefits Survey	IKN Children's Dental Benefits Survey - 508.pdf		Yes	Yes	Fillable Printable
Other-Screenshot: Summary of Benefits Form			Summary of Benefits Page - PRA Text.png		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicaid Drug Rebate Program

FR Citation: 78 FR 15744

Number of Respondents: 51

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	Previously Approved
Annual Number of Responses for this IC	51	0	51
Annual IC Time Burden (Hours)	1,275	25	1,250
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crossswalk	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.