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State Agency Contact Form (CMS-368)

IC 8197 under ICR 202404-0938-010 · OMB 0938-0582.

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State Agency Contact Form (CMS-368)
 
No Unchanged
 
Required to Obtain or Retain Benefits
 

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_10.2021_Fillable_Final.pdf Yes Yes Fillable Printable

Health Health Care Services

 

10 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved 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 10 0 0 0 0 10
Annual IC Time Burden (Hours) 5 0 0 0 0 5
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk: Contact Form CMS-368 State Agency Contact Form_Crosswalk_10.2021.pdf 02/17/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.