CMS-10398 #17 Non-Financial Eligibility - Non-Payment of Premiums

CHIP Eligibility
OMB Control Number: 0938‐1148

Separate Child Health Insurance Program
Non-Financial Eligibility - Non-Payment of Premiums

CS21

42 CFR 457.570
Non-Payment of Premiums
Does the state impose premiums?

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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