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Federal forms, ICRs, and supporting documents

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GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports

IC 250101 under ICR 202401-0938-016 · OMB 0938-1148.

Documents and Forms
Document Name
Document Type
Form
Form
Other-Unwinding Data Report Specific
Other-Unwinding Data Report Specific
Form
Form
Form
Form
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

GenIC #66 (New): Medicaid and CHIP COVID 19 Public Health Emergency Unwinding Reports CMCS
 
Unchanged
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10398 #66 Screenshots: Unwinding Data Report #66 - Unwinding Data Report screen shots (2022 version 1).pdf Yes Yes Fillable Fileable
Other-Unwinding Data Report Specifications #66 - Unwinding Data Report specifications (2022 version 4).pdf Yes Yes Fillable Fileable
Form CMS-10398 # 66 Unwinding Data Report Workbook #66 Unwinding Data Report excel workbook (2022 version 3).xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10398 #66 State Renewals Report #66 State Renewals Report (2022 version 3).docx Yes Yes Fillable Fileable

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 896 0 0 0 0 896
Annual IC Time Burden (Hours) 14,224 0 0 0 0 14,224
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
SHO letter 21002 August 2021 SHO Letter 21002 August 2021.pdf 02/28/2022
Placeholder: SHO letter 2200X March 2022 Placeholder - SHO Letter 2200X March 2022.docx 02/28/2022
Generic Supporting Statement #66 - Generic Supporting Statement (2022 version 6).docx 02/28/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.