Information Collection

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

IC 214452 under ICR 202409-0938-001 · OMB 0938-1268.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-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 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
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

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.