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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.