Information Collection

Limited Wraparound Coverage Reporting

IC 230945 under ICR 201804-0938-002 · OMB 0938-1351.

Documents and Forms

Document Name Document Type
Form CMS-10571 Limited Wraparound Coverage Reporting Form and Instruction
CMS-10571 Wraparound Coverage Reporting Form CMS-10571 Wraparound questions and instructions 61218 final.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Limited Wraparound Coverage Reporting	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 146.145(b)(vii)(E)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10571	Wraparound Coverage Reporting Form	CMS-10571 Wraparound questions and instructions 61218 final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	8	8
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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