GenIC #1 (Extension) - Initial Application

Medicaid and CHIP Program (MACPro) (CMS-10434)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1188 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10434 #1 GenIC #1 (Extension) - Initial Application Form
PRA Disclosure Statement 082919 (rev 08-30-2019).pdf Other-PRA Disclosure Statement
CMS-10434 #1 Initial Application Combined #1 Initial Application Combined.pdf Form
CMS-10434 #1 Initial Application SPA Admin 1 - Initial Application SPA Admin.pdf Form
CMS-10434 #1 Initial Application 1 - Initial Application.pdf Form
1 - Supporting Statement Initial Application Templates 082919.docx GenIC Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	GenIC #1 (Extension) - Initial Application	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10434 #1	Initial Application Combined	#1 Initial Application Combined.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #1	Initial Application SPA Admin	1 - Initial Application SPA Admin.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #1	Initial Application	1 - Initial Application.pdf	Yes	Yes	Fillable Fileable
Other-PRA Disclosure Statement			PRA Disclosure Statement 082919 (rev 08-30-2019).pdf	No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	476	476
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
GenIC Supporting Statement	1 - Supporting Statement Initial Application Templates 082919.docx	08/30/2019

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