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GenIC 22 (Revision): Health Home State Plan Amendment (SPA) CMCS
 
New
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form A1 - A5, HH1 - HH9, I1 - I5, and S (misc.) Yes Yes Fillable Fileable
Form HH1A Yes Yes Fillable Fileable
Form HH2A Yes Yes Fillable Fileable
Form HH3A Yes Yes Fillable Fileable
Form HH4A Yes Yes Fillable Fileable
Form HH5A Yes Yes Fillable Fileable
Form HH6A Yes Yes Fillable Fileable
Form HH7A Yes Yes Fillable Fileable
Form HH8A Yes Yes Fillable Fileable
Form HH9A Yes Yes Fillable Fileable
Form I2A Yes Yes Fillable Fileable
Form I3A Yes Yes Fillable Fileable
Form I3aA Yes Yes Fillable Fileable
Form I4A Yes Yes Fillable Fileable
Form I5A Yes Yes Fillable Fileable
Instruction Yes No Printable Only
Instruction Yes No Printable Only
Instruction Yes No Printable Only
Instruction Yes No Printable Only

Health Health Care Services

 

20 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 20 0 20 0 0 0
Annual IC Time Burden (Hours) 1,600 0 1,600 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
SMDL #10-024 08/02/2022
SMDL #22-004 08/02/2022
GenIC #22 - Generic Supporting Statement 08/02/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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