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Federal forms, ICRs, and supporting documents

Information Collection

[Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application

IC 279184 under ICR 202409-0938-028 · OMB 0938-1148.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form GenIC #45
Demonstration Application [Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application		 Form and Instruction
Form GenIC #45
Compliance Checklist [Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application		 Form and Instruction
Guidance on Addition of CCBHCs to Existing State Demonstration Programs CLEAN 12.12.25.docx Other-Guidance on Addition of CCBHCs
Guidance for States Reporting Changes in Demonstration_12.16.25.pdf Other-Guidance for States Reporting
GenIC #45 Demonstration Application
2026 CCBHC Demonstration Application Clean_2.18.26.pdf 		Form and Instruction
GenIC #45 Compliance Checklist
CCBHC-ComplianceChecklist-State Clean_12.10.25_508.pdf 		Form and Instruction
GenIC #45 - Generic Supporting Staement (2026 version 5).docx
Generic Supporting Statement		IC Document
45 - Demonstration Application Changes Crosswalk 2.18.26.pdf
Demonstration Application: Crosswalk		IC Document
2026 CCBHC Demonstration Application Redline_2.18.26.docx
Demonstration Application: Redline		IC Document
CCBHC-ComplianceChecklist-State Redline_12.10.25.docx
Compliance Checklist: Redline		IC Document
Guidance on Addition of CCBHCs to Existing State Demonstration Programs REDLINE 12.12.25.docx
Guidance on Addition of CCBHCs: Redline		IC Document
#45 Response to Public Comments_2.18.26.docx
Response to Public Comments		IC Document
Comment - ml9-rm5r-sfsp.pdf
Comment (H Consulting Solutions)		IC Document
Comment - mle-gq2t-quiu.pdf
Comment (Anonymous)		IC Document
Comment - mlh-7fld-mpg6.pdf
Comment (Health Management)		IC Document
Comment - mlp-hsqu-8swr.pdf
Comment (CrescentCare)		IC Document
Comment - mlp-iese-776a.pdf
Comment (Health Management)		IC Document
Comment - mlq-wd0g-61b1.pdf
Comment (NJAMHAA)		IC Document
Comment - mlr-5k7n-y74s.pdf
Comment (Anonymous)		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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 GenIC #45 Yes Yes Fillable Fileable
Form and Instruction GenIC #45 Yes Yes Fillable Fileable
Other-Guidance on Addition of CCBHCs Yes No Printable Only
Other-Guidance for States Reporting Changes Yes No Printable Only

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  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 43 0 43 0 0 0
Annual IC Time Burden (Hours) 194 0 194 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Generic Supporting Statement 02/23/2026
Demonstration Application: Crosswalk 02/23/2026
Demonstration Application: Redline 02/23/2026
Compliance Checklist: Redline 02/23/2026
Guidance on Addition of CCBHCs: Redline 02/23/2026
Response to Public Comments 02/23/2026
Comment (H Consulting Solutions) 02/23/2026
Comment (Anonymous) 02/23/2026
Comment (Health Management) 02/23/2026
Comment (CrescentCare) 02/23/2026
Comment (Health Management) 02/23/2026
Comment (NJAMHAA) 02/23/2026
Comment (Anonymous) 02/23/2026
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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