Information Collection

SMART SBE Annual Alternative Redeterninations Template

IC 254986 under ICR 202208-0938-002 · OMB 0938-1244.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1244 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10507 SMART SBE Annual Alternative Redeterninations Template	Form and Instruction
CMS-10507 SMART SBE Annual Alternative Redeterminations Template CMS-10507. SMART SBE Annual Alternative Redeterminations Template.pdf	Form and Instruction
CMS-10507 SMART SBE Annual Alternative Redeterminations Template CMS-10507. SMART SBE Annual Alternative Redeterminations Template.pdf	Form and Instruction

IC Title:

SMART SBE Annual Alternative Redeterninations Template

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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 and Instruction	CMS-10507	SMART SBE Annual Alternative Redeterminations Template	CMS-10507. SMART SBE Annual Alternative Redeterminations Template.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3	3
Annual IC Time Burden (Hours)	573	573
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.