Information Collection

Medicaid Use Report -- 20 CFR 216.628

IC 9168 under ICR 199912-0960-002 · OMB 0960-0267.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0267 can be found here:

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Information Collection (IC) Details

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IC Title:	Medicaid Use Report -- 20 CFR 216.628	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	60,000	35,000	25,000
Annual IC Time Burden (Hours)	3,000	1,750	1,250
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.