Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
GenIC #26 (Revision): Child and Adult Core Set Measures New 357 1066 0 Form and Instruction AQM-01
Form and Instruction AQM-02
Form and Instruction AQM-03
Form and Instruction AQM-04
Form and Instruction AQM-05
Form and Instruction AQM-06
Form and Instruction AQM-07
Form and Instruction AQM-08
Form and Instruction AQM-09
Form and Instruction AQM-10
Form and Instruction AQM-11
Form and Instruction AQM-12
Form and Instruction AQM-13 PQI 01
Form and Instruction AQM-14 PQI 05
Form and Instruction AQM-15 PQI 15
Form and Instruction AQM-16 PQI 08
Form and Instruction AQM-17
Form and Instruction AQM-18
Form and Instruction AQM-19
Form and Instruction AQM-20
Form and Instruction AQM-21
Form and Instruction AQM-22
Form and Instruction AQM-23
Form and Instruction AQM-24
Form and Instruction AQM-25
Form and Instruction AQM-26
Form and Instruction AQM-27
Form and Instruction AQM-28
Form and Instruction AQM-29
Form and Instruction AQM-30
Form and Instruction AQM-31
Form and Instruction AQM-32
Form and Instruction AQM-33
Form and Instruction AQM-34
Form and Instruction AQM-35
Form and Instruction AQM-36
Form and Instruction AQM-37
Form and Instruction AQM-38
Form and Instruction AQM-39
Form AQM-40
Form and Instruction CQM-01
Form and Instruction CQM-02
Form and Instruction CQM-03
Form and Instruction CQM-04
Form and Instruction CQM-05
Form and Instruction CQM-06
Form and Instruction CQM-07
Form and Instruction CQM-08
Form and Instruction CQM-09
Form and Instruction CQM-10
Form and Instruction CQM-11
Form and Instruction CQM-12
Form and Instruction CQM-13
Form and Instruction CQM-14
Form and Instruction CQM-15
Form and Instruction CQM-16
Form and Instruction CQM-17
Form and Instruction CQM-18
Form and Instruction CQM-19
Form and Instruction CQM-20
Form and Instruction CQM-21
Form and Instruction CQM-22
Form and Instruction CQM-23
Form and Instruction CQM-25
Form and Instruction CQM-26
Form and Instruction CQM-27
Form and Instruction CQM-28
Form and Instruction CQM-29
Form and Instruction CQM-30
Form and Instruction SQM-01
Form and Instruction CQM-24
GenIC #47 (Revised):Health Home Core Sets New 1 5 0 Form and Instruction HHQM-01
Form and Instruction HHQM-02
Form and Instruction HHQM-03
Form and Instruction HHQM-04
Form and Instruction HHQM-05
Form and Instruction HHQM-06
Form and Instruction HHQM-07
Form and Instruction HHQM-08
Form and Instruction HHQM-09
Form and Instruction HHQM-11
Form and Instruction HHQM-14
Form and Instruction HHQM-15
Form and Instruction HHQM-15
Form and Instruction HHQM-13
GenIC #66 (Revision): Eligibility Processing Data Report and Renewal Compliance Template New 1400 21056 0 Form and Instruction CMS-10398 #66
Other-Eligibility Processing Data Report Specifications
Form CMS-10398 #66
Form CMS-10398 #66
Other-SHO Letter 24-002
GenIC #66 (Revision): Medicaid and Children's Health Insurance Program Eligibility Processing Data Report New 1344 18816 0 Form CMS-10398 #66
Instruction
Form CMS-10398 #66
Other-SHO Letter
Used Burden (GenIC Inventory) New 696 20712 0 Other-GenIC Inventory
[Medicaid] GenIC #15 (Revision): Medicaid State Plan Eligibility New 100 1936 0 Form and Instruction RU A1
Form and Instruction RU A2
Form and Instruction RU A3
Form and Instruction RU A4
Form and Instruction RU A5
Form and Instruction RU I1
Form and Instruction RU I2
Form and Instruction RU I3
Form and Instruction RU I4
Form and Instruction RU I5
Form and Instruction RU S2
Form and Instruction RU S2t
Form and Instruction RU S3
Form and Instruction RU S3a
Form and Instruction RU S4
Form and Instruction RU S10
Form and Instruction RU S10t
Form and Instruction RU S11
Form and Instruction RU S11a
Form and Instruction RU S13a
Form and Instruction RU S14
Form and Instruction RU S14a
Form and Instruction RU S14t
Form and Instruction RU S16
Form and Instruction RU S17
Form and Instruction RU S21
Form and Instruction RU S25
Form and Instruction RU S25a
Form and Instruction RU S28
Form and Instruction RU S28a
Form and Instruction RU S28t
Form and Instruction RU S30
Form and Instruction RU S30t
Form and Instruction RU S32
Form and Instruction RU S32a
Form and Instruction RU S32t
Form and Instruction RU S33
Form and Instruction RU S33a
Form and Instruction RU S50
Form and Instruction RU S50a
Form and Instruction RU S51
Form and Instruction RU S52
Form and Instruction RU S53
Form and Instruction RU S54
Form and Instruction RU S55
Form and Instruction RU S57
Form and Instruction RU S59
Form and Instruction RU S59a
Form and Instruction RU S88
Form and Instruction RU S89
Form and Instruction RU S94
Form and Instruction RU S94a
Form and Instruction RU S97
Instruction
[Medicaid] GenIC #15 (Revision): Medicaid State Plan Eligibility New 56 5 0 Form and Instruction A1
Form and Instruction A2
Form and Instruction A3
Form and Instruction A4
Form and Instruction A5
Form and Instruction I1
Form and Instruction I2
Form and Instruction I3
Form and Instruction I4
Form and Instruction I5
Form and Instruction S2
Form and Instruction S2T
Form and Instruction S3
Form and Instruction S3A
Form and Instruction S4
Form and Instruction S10
Form and Instruction S10T
Form and Instruction S11
Form and Instruction S11A
Form and Instruction S13A
Form and Instruction S14
Form and Instruction S14A
Form and Instruction S14T
Form and Instruction S16
Form and Instruction S17
Form and Instruction S21
Form and Instruction S25
Form and Instruction S25A
Form and Instruction S28
Form and Instruction S28A
Form and Instruction S28T
Form and Instruction S30
Form and Instruction S30T
Form and Instruction S32
Form and Instruction S32A
Form and Instruction S32T
Form and Instruction S33
Form and Instruction S33A
Form and Instruction S50
Form and Instruction S50A
Form and Instruction S51
Form and Instruction S52
Form and Instruction S53
Form and Instruction S54
Form and Instruction S55
Form and Instruction S57
Form and Instruction S59
Form and Instruction S59A
Form and Instruction S88
Form and Instruction S89 (revised)
Form and Instruction S94
Form and Instruction S94A
[Medicaid] GenIC #26 (Nonsubstantive Change): Child and Adult Core Set Measures New 1 5 0
[Medicaid] GenIC #26 (Revised): Child and Adult Core Set Measures New 61098 98911 0 Form and Instruction AQM-01
Form and Instruction AQM-02
Form and Instruction AQM-03
Form and Instruction QM-04
Form and Instruction AQM-05
Form and Instruction AQM-06
Form and Instruction AQM-07
Form and Instruction AQM-08
Form and Instruction AQM-09
Form and Instruction AQM-10
Form and Instruction AQM-11
Form and Instruction AQM-12
Form and Instruction AQM-14, PQI 05
Form and Instruction AQM-13, PQI 01
Form and Instruction AQM-14, PQI 05
Form and Instruction AQM-15, PQI 15
Form and Instruction AQM-16, PQI 08
Form and Instruction AQM-17
Form and Instruction AQM-18
Form and Instruction AQM-19
Form and Instruction AQM-20
Form and Instruction AQM-21
Form and Instruction AQM-22
Form and Instruction AQM-23
Form and Instruction AQM-24
Form and Instruction AQM-25
Form and Instruction AQM-26
Form and Instruction AQM-27
Form and Instruction AQM-28
Form and Instruction AQM-29
Form and Instruction AQM-30
Form and Instruction AQM-31
Form and Instruction AQM-32
Form and Instruction AQM-33
Form and Instruction AQM-34
Form and Instruction CQM-01
Form and Instruction CQM-02
Form and Instruction CQM-03
Form and Instruction CQM-04
Form and Instruction CQM-05
Form and Instruction CQM-06
Form and Instruction CQM-07
Form and Instruction CQM-08
Form and Instruction CQM-09
Form and Instruction CQM-10
Form and Instruction CQM-11
Form and Instruction CQM-12
Form and Instruction CQM-13
Form and Instruction CQM-14
Form and Instruction CQM-15
Form and Instruction CQM-16
Form and Instruction CQM-17
Form and Instruction CQM-18
Form and Instruction CQM-19
Form and Instruction CQM-20
Form and Instruction CQM-21
Form and Instruction CQM-22
Form and Instruction CQM-23
Form and Instruction CQM-24
Form and Instruction CQM-25
Form and Instruction CQM-26
Form and Instruction CQM-27
Form and Instruction CQM-28
Form CMS-10434 #26
Other-SPA Implementation Guide
[Medicaid] GenIC #47 (Revised): Health Home Core Sets New 104 5754 0 Form and Instruction HHQM - 01
Form and Instruction HHQM - 02
Form and Instruction HHQM - 03
Form and Instruction HHQM - 04
Form and Instruction HHQM-05
Form and Instruction HHQM - 06
Form and Instruction HHQM - 07
Form and Instruction HHQM - 08
Form and Instruction HHQM - 09
Form and Instruction HHQM - 10
Form and Instruction HHQM - 11
Form and Instruction HHQM - 12
Form and Instruction HHQM - 13
Form and Instruction HHQM - 14
[Medicaid] GenIC #47 (non-Substantive Change): Health Home Core Sets New 1 5 0
[Medicaid] GenIC #82 (New): Quality Improvement Affinity Group Expression of Interest Form New 20 60 0 Form and Instruction GenIC #82
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 65178 168331 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 100 5 0  
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