Client Contact Form

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0850 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10028 Client Contact Form Form
CMS-10028 CMS-10028. Client Contact Form Client_Contact_Form_Certified (2).pdf Form

Information Collection (IC) Details

IC Title:	Client Contact Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10028	CMS-10028. Client Contact Form	Client_Contact_Form_Certified (2).pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12,407	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,621,223	1,621,223
Annual IC Time Burden (Hours)	135,102	135,102
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.