Information Collection

Medicaid Use Report

IC 9170 under ICR 201112-0960-003 · OMB 0960-0267.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
MSSICS Screens.doc	Other-MSSICS
PRA and PA Statments.doc PRA and PA Statments	IC Document

IC Title:

Medicaid Use Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.268

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-MSSICS					Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

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: 98 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	60,000	60,000
Annual IC Time Burden (Hours)	3,000	3,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PRA and PA Statments		12/06/2011

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].