SBC Disclosure

OMB control number: 0938-1146
Expiration Date: XX/20XX

Maternity Care
A healthy, 28-year old woman decides to start a family and begins taking prenatal vitamins in January.
Her doctor confirms she is pregnant at the beginning of April. She receives routine, prenatal care as
recommended by national guidelines. In December, she gives birth to a healthy child; the delivery is
normal and uncomplicated. Mother and child are released on the second hospital day. The mother is
discharged with a stool softener and a prescription for pain medications.

DISCLAIMER: This narrative and the accompanying benefit scenario illustrate care for a hypothetical
patient receiving maternity care. The care, and cost of care, will vary for each patient. No portion of this
narrative or the accompanying benefit scenario should be construed as recommendations for care, or
cost of care, by the United States Government.

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete
this information collection is estimated to average XXX hours per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146