Information Collection

Medicaid Promoting Interoperability Program Document Templates

IC 192702 under ICR 202102-0938-009 · OMB 0938-1088.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10292 HIT PAPD Template (2020 version 2).pdf	Instruction
CMS-10292 HIT PAPD Template (2020 version 2).pdf	Instruction
CMS-10292 State Medicaid HIT Plan Template (2020 version 2).pdf	Instruction
CMS-10292 State Medicaid HIT Plan Template (2020 version 2).pdf	Instruction
CMS-10292 Health Information Technology (HIT) Implementation Advan CMS-10292 HIT IAPD Template (2020 version 2).pdf	Form and Instruction
CMS-10292 Health Information Technology (HIT) Implementation Advan CMS-10292 HIT IAPD Template (2020 version 2).pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-10292 HIT PAPD Template (2020 version 2).pdf	Yes	Yes	Fillable Printable
Instruction			CMS-10292 State Medicaid HIT Plan Template (2020 version 2).pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10292	Health Information Technology (HIT) Implementation Advanced Planning Document (IAPD)	CMS-10292 HIT IAPD Template (2020 version 2).pdf	Yes	Yes	Fillable Printable

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	896	896
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.