Information Collection

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

IC 43677 under ICR 201309-0938-030 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Children's Health Insurance Program (CHIP) Report on Payables and Receivables	Form
CMS-10180 Validation Letter.doc	Instruction
CMS-10180 IBNR CMS-10180 Revised Form (2011).doc	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	IBNR	CMS-10180 Revised Form (2011).doc		No	No	Fillable Fileable
Instruction			CMS-10180 Validation Letter.doc		No	No	Fillable Printable

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	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	56	0	56
Annual IC Time Burden (Hours)	392	56	336
Annual IC Cost Burden (Dollars)	0	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.