Information Collection

State Agency Contact Form (CMS-368)

IC 8197 under ICR 202003-0938-010 · OMB 0938-0582.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0582 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-368 State Agency Contact Form (CMS-368) Form
CMS-368 State Agency Contact Form CMS-368 State Agency Contact Form_12.2019_Final.docx Form
CMS-368 State Agency Contact Form_12.2019_TC.docx Track Changes: Contact Form IC Document
CMS-368 State Agency Contact Form_Crosswalk_12.2019.xlsx Crosswalk: Contact Form IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State Agency Contact Form (CMS-368)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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-368	State Agency Contact Form	CMS-368 State Agency Contact Form_12.2019_Final.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Track Changes: Contact Form	CMS-368 State Agency Contact Form_12.2019_TC.docx	04/09/2020
Crosswalk: Contact Form	CMS-368 State Agency Contact Form_Crosswalk_12.2019.xlsx	04/09/2020

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