Information Collection

Collection of Dental Benefit Information

IC 189779 under ICR 202101-0938-010 · OMB 0938-1065.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1065 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10291 Collection of Dental Benefit Information	Form
Summary of Benefits Page - PRA Text.png	Other-Screenshot: Summary of Benefit
Summary of Benefits Page - PRA Text.png	Other-Screenshot: Summary of Benefit
CMS-10291 Insure Kids Now Children’s Dental Benefits Survey SummaryofBenefitsFormPlain.pdf	Form
CMS-10291 Insure Kids Now Children’s Dental Benefits Survey SummaryofBenefitsFormPlain.pdf	Form

IC Title:

Collection of Dental Benefit Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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-10291	Insure Kids Now Childrenâs Dental Benefits Survey	SummaryofBenefitsFormPlain.pdf		Yes	Yes	Fillable Printable
Other-Screenshot: Summary of Benefits Form			Summary of Benefits Page - PRA Text.png		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicaid Drug Rebate Program

FR Citation: 78 FR 15744

Number of Respondents: 51

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
	Approved	Previously Approved
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	1,275	1,275
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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