SHIP/MIPPA Beneficiary Client Form

State Health Insurance Assistance Program (SHIP) Client Contact Forms

Documents and Forms

Document Name Document Type
SHIP/MIPPA Beneficiary Client Form Form and Instruction
STARS BCF 0040 STARS BCF 2023 Ins 9.docx Form and Instruction
STARS BCF 0040 STARS BCF 2023 Ins 9.docx Form and Instruction

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	STARS BCF	0040 STARS BCF 2023 Ins 9.docx		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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,495,000	3,495,000
Annual IC Time Burden (Hours)	291,250	291,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.