Information Collection

State Agency Contact Form (CMS-368)

IC 8197 under ICR 202102-0938-017 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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_07.2021_Final.docx	Form
CMS-368 State Agency Contact Form CMS-368 State Agency Contact Form_07.2021_Final.docx	Form
CMS-368 State Agency Contact Form_Crosswalk_07.2021.xlsx CMS-368 - Crosswalk	IC Document
CMS-368 State Agency Contact Form_Crosswalk_07.2021.xlsx CMS-368 - Crosswalk	IC Document

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:

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-368	State Agency Contact Form	CMS-368 State Agency Contact Form_07.2021_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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
CMS-368 - Crosswalk	CMS-368 State Agency Contact Form_Crosswalk_07.2021.xlsx	02/27/2021

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