View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations	Agency IC Tracking Number:	CMCS

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398. GenIC #59				Yes	Yes	Fillable Fileable
Form	CMS-10398. GenIC#59				Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398. GenIC #59				Yes	Yes	Fillable Fileable
Instruction					Yes	Yes	Printable Only
Instruction					Yes	Yes	Printable Only
Form	CMS-10398. GenIC#59				Yes	Yes	Fillable Fileable
Form	CMS-10398. GenIC #59				Yes	Yes	Fillable Fileable
Instruction					Yes	Yes	Printable Only
Form and Instruction	CMS-10398.GenIC#59				Yes	Yes	Fillable Fileable
Instruction					Yes	Yes	Printable Only
Instruction					Yes	Yes	Printable Only
Instruction				https://cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/	Yes	Yes	Fillable Fileable
Instruction				https://cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/	Yes	Yes	Fillable Fileable
Instruction				https://cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/	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: 10	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	114	0	0	0	0	114
Annual IC Time Burden (Hours)	3,314	0	0	0	0	3,314
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
GenIC #59 - Generic Supporting Statement (2022 v7 final 5-19-22)		05/19/2022
Attachment 11.a - g. SMI _SED Demonstration Implementation Docs		05/19/2022

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.