View Information Collection (IC)

View Information Collection (IC)

IC Title:	GenIC #22 (Extension) - Health Home State Plan Amendment (SPA)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10434 #22	Health Homes	#22 Health Homes.pdf		Yes	Yes	Fillable Fileable
Other-PRA Disclosure Statement			PRA Disclosure Statement 082919 (rev 08-30-2019).pdf		No		Printable Only

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: 30	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	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	30	0	30	0	0	0
Annual IC Time Burden (Hours)	2,400	0	2,400	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
GenIC Supporting Statement	GenIC 22 - Supporting Statement Health Home SPA (version8).docx	08/30/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.