Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template

Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template (CMS-10536)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1268 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10536 Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template Form and Instruction
CMS-10536 Medicaid Eligibility and Enrollment (EE) Implementation Medicaid_EE_IAPD_Template (2021 version 1).pdf Form and Instruction
CMS-10536 Medicaid Eligibility and Enrollment (EE) Implementation Medicaid_EE_IAPD_Template (2021 version 1).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10536	Medicaid Eligibility and Enrollment (EE) Implementation Advanced Planning Document (IAPD) Template	Medicaid_EE_IAPD_Template (2021 version 1).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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	168	168
Annual IC Time Burden (Hours)	2,688	2,688
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.