RECIPIENT, USE AND EXPENDITURES FOR MEDICAID ENROLLEES COVERED UNDER SECTION 1619(A) AND (B) OF THE SOCIAL SECURITY ACT

ICR 198608-0938-019

OMB: 0938-0446

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0446 198608-0938-019
Historical Active 198508-0938-008
HHS/CMS
RECIPIENT, USE AND EXPENDITURES FOR MEDICAID ENROLLEES COVERED UNDER SECTION 1619(A) AND (B) OF THE SOCIAL SECURITY ACT
No material or nonsubstantive change to a currently approved collection   No
Emergency 08/01/1986
Approved with change 08/01/1986
Retrieve Notice of Action (NOA) 08/01/1986
  Inventory as of this Action Requested Previously Approved
09/30/1986 09/30/1986 09/30/1986
50 0 50
1,015 0 7,250
0 0 0

THE 3-PAGE QUESTIONNAIRE WILL COLLECT DATA FROM STATE MEDICAID AGENCIE RELATING TO RECIPIENTS OF MEDICAID SERVICES UNDER SECTION 1619(A) AND (B) OF THE SOCIAL SECURITY ACT. HCFA WILL USE THE COLLECTED DATA TO MAKE RECOMMENDATIONS REGARDING THE CONTINUATION AND/OR NEEDED MODIFICATION TO THAT PROVISION.

None
None


No

1
IC Title Form No. Form Name
RECIPIENT, USE AND EXPENDITURES FOR MEDICAID ENROLLEES COVERED UNDER SECTION 1619(A) AND (B) OF THE SOCIAL SECURITY ACT HCFA-498

  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 50 50 0 0 0 0
Annual Time Burden (Hours) 1,015 7,250 0 0 -6,235 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
08/01/1986


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