OMB control number

Medicaid Incentives for Prevention of Chronic Diseases Evaluation (CMS-10477)

OMB 0938-1219 · HHS/CMS.

OMB 0938-1219

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10477 Administrative Cost Forms for MIPCD Form and Instruction
Form CMS-10477 Beneficiary Satisfaction Survey Form and Instruction
Form CMS-10477 Focus Groups Form and Instruction
Form CMS-10477 Stakeholder Interview Form and Instruction
Form CMS-10477 Site Visit Interviews Form and Instruction
MIPCDSupportStatementPartB.pdf Supporting Statement B
Attachment_6e_Reminder_Letter.pdf Supplementary Document
Attachment_6b_Survey_Cover_Letter.pdf Supplementary Document
Attachment_6a_Prenotification_Letter.pdf Supplementary Document
Attachment_4c_Recruitment_Flyer_Template.pdf Supplementary Document
Attachment_4f_Reminder_Email.pdf Supplementary Document
Attachment_2b_Physician_Background_FAQ (revised).pdf Supplementary Document
Attachment_2a_Physician_Interview_Email_Invitation.pdf Supplementary Document
Attachment_5b_Interview_Email_Invitation.pdf Supplementary Document
Attachment_5a_Background_FAQ.pdf Supplementary Document
MIPCD_Supp_State_Part_A_06_25_2014.docx Supporting Statement A
Administrative Cost Forms for MIPCD Form and Instruction
Beneficiary Satisfaction Survey Form and Instruction
Focus Groups Form and Instruction
Stakeholder Interview Form and Instruction
Site Visit Interviews Form and Instruction

All Historical Document Collections

201410-0938-001 Approved without change	Revision of a currently approved collection	2014-10-01
201308-0938-006 Approved with change	New collection (Request for a new OMB Control Number)	2013-08-07