CMS-10398 #17 Non-Financial Eligibility - Social Security Number

CHIP Eligibility
OMB Control Number: 0938‐1148

Separate Child Health Insurance Program
Non-Financial Eligibility - Social Security Number

CS19

42 CFR 457.340(b)
Social Security Number
As a condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as
determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one
number.
The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following
exceptions:
Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or
Individuals who are not eligible for an SSN, or
Individuals who are issued an SSN only for a valid non-work purpose.
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The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social
Security Administration if the individual does not have or forgot their SSN.

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The CHIP Agency informs individuals required to provide their SSN:
By what statutory authority the number is solicited; and
How the state will use the SSN.
The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social
Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the
individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205
and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.
The state requests non-applicant household members to voluntarily provide their
SSN.

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 0938-1148 (CMS-10398 #17). The time
required to complete this information collection is estimated to average 50 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 21244-1850.

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