Information Collection

SHIP/MIPPA Beneficiary Client Form

IC 193277 under ICR 202009-0985-002 · OMB 0985-0040.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0985-0040 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 SHIP/MIPPA Beneficiary Client Form	Form and Instruction
1 Beneficiary Contact Form 0040 (1) Beneficiary Contact Form Fin 20.pdf	Form and Instruction

IC Title:

SHIP/MIPPA Beneficiary Client Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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 and Instruction	1	Beneficiary Contact Form	0040 (1) Beneficiary Contact Form Fin 20.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,000

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,495,000	-107,025	3,602,025
Annual IC Time Burden (Hours)	291,250	81,262	209,988
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.