Information Collection

Preparation for and mailing of the CMS-29 Form to the State agencies

IC 230988 under ICR 201808-0938-008 · OMB 0938-0074.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0074 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Preparation for and mailing of the CMS-29 Form to the State agencies	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 491.1-491.11

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 210	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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	210	210
Annual IC Time Burden (Hours)	35	35
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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