View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

Bundle: (GenIC 1) Sec. 1915(b)(4) Waiver Application - Fee For Service Selective Contracting Program & (GenIC 2) Sec. 1115 Demo and Waiver Application
 
New
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction Yes No Fillable Printable
Form and Instruction CMS-10398-009 Yes Yes Fillable Printable
Form CMS-10398-10 Yes Yes Fillable Printable
Other-1115 Demo - Information on Cost Sharing Requirements Yes No Printable Only
Form CMS-10398-10 Yes Yes Fillable Printable
Form CMS-10398-10 Yes Yes Fillable Printable
Form and Instruction CMS-10398-10 Yes Yes Fillable Printable
Form and Instruction CMS-10398-10 Yes Yes Fillable Printable
Other-1115 Demo - List of Medicaid Eligibility Groups Yes No Fillable Printable
Other-1115 Demo - List of Medicaid and CHIP Benefits Yes No Fillable Printable
Form CMS-10398-10 Yes Yes Fillable Fileable
Form CMS-10398-10 Yes Yes Fillable Printable

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   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 112 0 0 0 0 0
Annual IC Time Burden (Hours) 4,480 0 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Supporting Statement - 1115 Demonstration and Waiver Application 07/11/2012
Supporting Statement - Application for Section 1915(b)(4) Waiver 07/11/2012
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
Something went wrong when downloading this file. If you have any questions, please send an email to risc@gsa.gov.