Information Collection

GenIC #22 (Extension) - Health Home State Plan Amendment (SPA)

IC 237599 under ICR 201908-0938-015 · OMB 0938-1188.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10434 #22 GenIC #22 (Extension) - Health Home State Plan Amendment (SPA)	Form
PRA Disclosure Statement 082919 (rev 08-30-2019).pdf	Other-PRA Disclosure Statement
CMS-10434 #22 Health Homes #22 Health Homes.pdf	Form
GenIC 22 - Supporting Statement Health Home SPA (version8).docx GenIC Supporting Statement	IC Document

IC Title:

GenIC #22 (Extension) - Health Home State Plan Amendment (SPA)

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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-10434 #22	Health Homes	#22 Health Homes.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: 30

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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	2,400	2,400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
GenIC Supporting Statement	GenIC 22 - Supporting Statement Health Home SPA (version8).docx	08/30/2019

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