HEALTH INSURANCE INFORMATION REQUEST

ICR 198212-0960-008

OMB: 0960-0323

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
115308 Migrated
ICR Details
0960-0323 198212-0960-008
Historical Active
SSA
HEALTH INSURANCE INFORMATION REQUEST
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 01/26/1983
Retrieve Notice of Action (NOA) 12/03/1982
  Inventory as of this Action Requested Previously Approved
12/31/1984 12/31/1984
90,000 0 0
7,500 0 0
0 0 0

TO ENSURE THAT MEDICAID IS A PAYOR OF LAST RESORT, THE MEDICAID STATUT REQUIRES THAT MEDICAID STATE AGENCIES TAKE ALL REASONABLE MEASURES TO ASCERTAIN THE LEGAL LIABILITY OF THIRD PARTIES TO PAY FOR MEDICAL EXPENSES OF MEDICAID APPLICANTS/RECIPIENTS. FORM SSA-8019 ELICITS INFORMATION FROM MEDICAID APPLICANTS/RECIPIENTS WHO ARE BENEFICIARIES OF A HEALTH INSURANCE RESOURCE. THIS INFORMATION IS THEN TRANSFERRED THE MEDICAID STATE AGENCY.

None
None


No

1
IC Title Form No. Form Name
HEALTH INSURANCE INFORMATION REQUEST SSA-8019

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 90,000 0 0 90,000 0 0
Annual Time Burden (Hours) 7,500 0 0 7,500 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
12/03/1982


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