Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
State Plan preprints to implement Sections of the Deficit Reduction Act of 2006 and Third-party Disclosure for Non-emergencies (CMS-10190)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Voluntary
CFR Citation:
42 CFR 1396
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
CMS-10190
DRA 6041 Costsharing Preprint
DRA 6041CostsharingPreprint revised Att 4 18-F clean.doc
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10190
DRA 6042 costsharing preprint
DRA 6042costsharingpreprint revised Att 4 18-G clean.doc
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10190
nem3 1d
508ed_nem3 1d.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10190
Non-Emergency Medical Transportation preprint
508ed_nemtbrokerpreprintBespa6-5-09.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10190
6044 Benchmark Preprint
PRA 508ed_Benchmark Preprint Sec 3 1-C version4 7-21- 09.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
16
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
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
16
0
-40
0
0
56
Annual IC Time Burden (Hours)
32
0
-24
0
0
56
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
PRA Summary of Modifications to DRA Preprints
PRA Summary of Modifications to DRA Preprints.docx
10/23/2009
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.