Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
GenIC # 45 (Extension) - Maternal and Infant Health Quality New 112 112 0 Form CMS-10434 #45 Maternal and Infant Health
Other-PRA Disclosure Statement
GenIC #1 (Extension) - Initial Application New 56 476 0 Form CMS-10434 #1 Initial Application Combined
Form CMS-10434 #1 Initial Application SPA Admin
Form CMS-10434 #1 Initial Application
Other-PRA Disclosure Statement
GenIC #15 (Extension) - Medicaid State Plan Eligibility New 56 1120 0 Form CMS-10434 #15 Medicaid State Plan Eligibility
Other-PRA Disclosure Statement
GenIC #2 (Extension) - CHIP State Plan Eligibility New 56 1568 0 Form CMS-10434 #2 CHIP State Plan Eligibility
Other-PRA Disclosure Statement
GenIC #22 (Extension) - Health Home State Plan Amendment (SPA) New 30 2400 0 Form CMS-10434 #22 Health Homes
Other-PRA Disclosure Statement
GenIC #26 (Extension) - Medicaid Adult and Child Core Set Measures New 224 8960 0 Other-PRA Disclosure Statement
Form and Instruction 390-CQM 2018-CCW-CH-PRA-D Contraceptive Care – All Women Ages 15-20 (CCW-CH)
Form and Instruction 385-CQM 2018-ADD-CH-PRA-D CQM 2018 - Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication (ADD-CH) Core Measure PRA Document
Form and Instruction 385-CQM 2018-ADD-CH-PRA-D CQM 2018 - Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication (ADD-CH) Core Measure PRA Document
Form and Instruction 429-AQM 2018 ABA-AD PRA-D AQM 2018 – Adult Body Mass Index Assessment (ABA) Core Measure PRA document
Form and Instruction 245-QSSI-MACPro-PRA-AdditionalNotes-D AQM, CQM & MIH - Additional Notes PRA document
GenIC #3 (Extension) - Alternative Benefit Plans (ABPs) New 56 728 0 Form CMS-10434 #3 ABP
Other-PRA Disclosure Statement
GenIC #47 (Extension) - Health Home Core Sets New 30 1200 0 Form CMS-10434 #47 Health Home Core Set
Other-PRA Disclosure Statement
GenIC #77 (New): Medicaid Extended Postpartum Coverage and Continuous Eligibility for Children New 56 2548 0 Form and Instruction CMS-10434 #77 Continuous Eligibility for Children (reviewable unit screenshots)
Form and Instruction CMS-10434 #77 Continuous Eligibility for Pregnant Women and Extended Postpartum Coverage (reviewable unit screenshots)
Form and Instruction CMS-10434 #77 Home Page and Initial Application Forms
GenIC 22 (Revision): Health Home State Plan Amendment (SPA) New 20 1600 0 Form A1 - A5, HH1 - HH9, I1 - I5, and S (misc.) 1945 Health Home SPA Templates
Form HH1A 1945A Health Homes Introduction
Form HH2A 1945A Population and Enrollment
Form HH3A 1945A Geographic Limitations
Form HH4A 1945A Health Homes Services
Form HH5A 1945A Health Homes Providers
Form HH6A 1945A Health Homes Delivery Systems
Form HH7A 1945A Health Homes Payment Methodologies
Form HH8A 1945A Health Homes Monitoring, Quality Measurement, and Evaluation
Form HH9A 1945A Health Homes Program Termination
Form I2A 1945A Submission Summary
Form I3A 1945A Public Comment
Form I3aA 1945A Public Notice-Process
Form I4A 1945A Tribal Input
Form I5A 1945A Other Comment
Instruction
Instruction
Instruction
Instruction
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 696 20712 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
To view an IC, click on IC Title