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
Other-PRA Disclosure Statement
GenIC #1 (Extension) - Initial Application New 56 476 0 Form CMS-10434 #1
Form CMS-10434 #1
Form CMS-10434 #1
Other-PRA Disclosure Statement
GenIC #15 (Extension) - Medicaid State Plan Eligibility New 56 1120 0 Form CMS-10434 #15
Other-PRA Disclosure Statement
GenIC #2 (Extension) - CHIP State Plan Eligibility New 56 1568 0 Form CMS-10434 #2
Other-PRA Disclosure Statement
GenIC #22 (Extension) - Health Home State Plan Amendment (SPA) New 30 2400 0 Form CMS-10434 #22
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
Form and Instruction 385-CQM 2018-ADD-CH-PRA-D
Form and Instruction 385-CQM 2018-ADD-CH-PRA-D
Form and Instruction 429-AQM 2018 ABA-AD PRA-D
Form and Instruction 245-QSSI-MACPro-PRA-AdditionalNotes-D
GenIC #3 (Extension) - Alternative Benefit Plans (ABPs) New 56 728 0 Form CMS-10434 #3
Other-PRA Disclosure Statement
GenIC #47 (Extension) - Health Home Core Sets New 30 1200 0 Form CMS-10434 #47
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
Form and Instruction CMS-10434 #77
Form and Instruction CMS-10434 #77
GenIC 22 (Revision): Health Home State Plan Amendment (SPA) New 20 1600 0 Form A1 - A5, HH1 - HH9, I1 - I5, and S (misc.)
Form HH1A
Form HH2A
Form HH3A
Form HH4A
Form HH5A
Form HH6A
Form HH7A
Form HH8A
Form HH9A
Form I2A
Form I3A
Form I3aA
Form I4A
Form I5A
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