Client Contact Form

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

OMB: 0938-0850

IC ID: 193277

Information Collection (IC) Details

View Information Collection (IC)

Client Contact Form
 
No New
 
Mandatory
 

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

Health Health Care Services

 

12,407 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 1,621,223 0 0 1,621,223 0 0
Annual IC Time Burden (Hours) 135,102 0 0 135,102 0 0
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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