CMS-10398 #17 General Eligibility - Presumptive Eligibility for Childr

CHIP Eligibility
OMB Control Number: 0938‐1148

Separate Child Health Insurance Program
General Eligibility - Presumptive Eligibility for Children

CS28

42 CFR 457.355 and 435.1102, 2107(e)(1)(L) and 1920A of the SSA
The CHIP Agency covers children when determined presumptively eligible by a qualified entity.

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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