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View Information Collection (IC)
View Information Collection (IC)
IC Title:
[Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application
Agency IC Tracking Number:
CMCS
IC Status:
New
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 and Instruction
CMS-10398 #45
Application and Guidance to Participate in the Section 223 CCBHC Demonstration Program
2024 CCBHC Demonstration Application- Fillable.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #45
Guidance on Addition of CCBHCs to Section 223 State Demonstration Programs
Guidance on Addition of CCBHCs to Section 223 State Demonstration Programs (SAMHSA OAS Approved).pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #45
Criteria Compliance Checklist
Criteria Compliance Checklist-State (6-28-23-SAMHSA OAS Approved).pdf
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:
30
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
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
30
0
30
0
0
0
Annual IC Time Burden (Hours)
1,790
0
1,790
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Generic Supporting Statement
GenIC #45 - Generic Supporting Statement (2023 version 9).docx
02/01/2024
Track Change: Demonstration Application
45 - CCBHC Demonstration Application- CMS SAMHSA Updates REDLINES 1-30-24 (004).docx
02/01/2024
Crosswalk: Demonstration Application
Demonstration Application Changes Crosswalk_CMS and SAMHSA 1-29-24_508.pdf
02/01/2024
Response to Public Comments
#45 CCBHC State Propoal Application_PRA Comment Responses 02-01-2024.pdf
02/01/2024
Public Comment 43jw (National Council for Mental Wellbeing)
lrp-ej3s-43jw - Comment.pdf
02/01/2024
Public Comment ya9i (affiliate.dhhs.nh.gov)
lrp-gu9v-ya9i - Cover Info and Comment.pdf
02/01/2024
Public Comment afry (healthmanagement.com)
lrp-i3cc-afry - Cover Info and Comment.pdf
02/01/2024
Public Comment a3nh (Myers and Stauffer, LC)
lrq-i6xj-a3nh - Cover Info and Comment.pdf
02/01/2024
Public Comment z9dd
lrq-t2w5-z9dd - Cover Info and Comment.pdf
02/01/2024
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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