Information Collection

Children's Health Insurance Program (CHIP) Report on Payables and Receivables

IC 43677 under ICR 200910-0938-006 · OMB 0938-0988.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0988 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10180 CHIP Incurred but Not Reported Survey Children's Health Insurance Program (CHIP) Report on Payables and Receivables	Form
CHIP Survey Instructions Final 1.pdf	Instruction
CMS-10180 CHIP Incurred but Not Reported Survey CHIP IBNR Survey Final .pdf	Form

IC Title:

Children's Health Insurance Program (CHIP) Report on Payables and Receivables

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10180				No	No	Fillable Fileable
Instruction					No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	336	336
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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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