Information Collection

CHIPRA 214 Option (§§ 435.4 and 457.320(c))

IC 261062 under ICR 202306-0938-010 · OMB 0938-1147.

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Information Collection (IC) Details

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IC Title:	CHIPRA 214 Option (§§ 435.4 and 457.320(c))	Agency IC Tracking Number:	CMCS

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 435.4 42 CFR 457.320(c)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 39	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,101	4,101
Annual IC Time Burden (Hours)	4,101	4,101
Annual IC Cost Burden (Dollars)	0	0

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