State Health Insurance Assistance Program (SHIP) Client Contact Form, Public and Media Activity Form, and Resource Report

State Health Insurance Assistance Program (SHIP) Client Contact Form, Pubic and Media Activity Form, and Resource Report Form.

OMB: 0938-0850

IC ID: 8663

Information Collection (IC) Details

View Information Collection (IC)

State Health Insurance Assistance Program (SHIP) Client Contact Form, Public and Media Activity Form, and Resource Report
 
No Modified
 
Mandatory
 
42 CFR 403.510

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10028-A State Health Insurance Assistance Program (SHIP) Client Contact Form CMS-10028-A Client Contact 12.06.pdf Yes Yes Paper Only
Instruction CMS-10028-A Client Contact InstManual 12.06.pdf Yes Yes Paper Only
Form CMS-10028-C State Health Insurance Assistance Program (SHIP) Resource Report Form CMS-10028-C Resource12.06.pdf Yes Yes Paper Only
Form CMS-10028-B State Health Insurance Assistance Program (SHIP) Public and Media Activity Form CMS-10028-B PAM_12.06.pdf Yes Yes Paper Only
Instruction CMS-10028-B PAM instructions 12.06.pdf Yes Yes Paper Only
Instruction CMS-10028-C Resource Rpt Form Inst 12.06.doc Yes Yes Paper Only

Health Health Care Services

 

12,000 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 1,056,000 0 0 56,000 0 1,000,000
Annual IC Time Burden (Hours) 87,965 0 0 -28,782 0 116,747
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
No associated records found
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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