MSSICS Screens (current)

COLLECTION INSTRUMENT – Medicaid Use Report – OMB #0960-0267

The beneficiary’s answers to the following questions must be recorded on a Statement of Claimant or Other Person (SSA-795), or in MSSICS on the DPST or DROC screens.

Per SI 02302.040, the individual should be asked:

• “Have you used any medical care or services in the past 12 months that was paid for by Medicaid (or Medi-Cal, etc.)?”

• “Do you expect to receive any medical care or services in the next 12 months that will be paid for by Medicaid (or Medi-Cal, etc.)?”

• “Without Medicaid (Medi-Cal, etc.), would you be unable to pay your medical bills if you become ill or injured in the next 12 months?”

Based on the individual’s allegations regarding Medicaid use, the technician will transmit the appropriate finding to the SSR per SM 01305.975.

FACSIMILE:  DPST - PERSON STATEMENT (MSOM 022.008)

MSSICS                              PERSON STATEMENT           PAGE 1 OF DPST

SSS-SS-SSSS                SSSSS SSSSSSSSSS                 TRANSFER TO: XXXX

SELECT CLAIMANT/PERSON: 99

NAME:                                                   RELATIONSHIP/TITLE

 1=SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSS SSSS

 2=SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSS SSSS

 3=SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSS SSSS

 4=SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSS SSSS

 5=SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSS SSSS

FACSIMILE:  DROC - REPORT OF CONTACT (MSOM 022.010)

MSSICS                  REPORT OF CONTACT               PAGE 1 OF DROC

SSS-SS-SSSS              SSSSS SSSSSSSSSS                 TRANSFER TO: XXXX

SELECT CLAIMANT/PERSON: 99

 NAME:                                                RELATIONSHIP/TITLE:

 1=SSSSSSSSSSSSSS SSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSS

 2=SSSSSSSSSSSSSS SSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSS

 3=SSSSSSSSSSSSSS SSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSS

 4=SSSSSSSSSSSSSS SSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSS

 5=SSSSSSSSSSSSSS SSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSS

Privacy Act and Paperwork Reduction Act Statements

Read to claimant before starting interview:

Social Security estimated that this interview would take 3 minutes to complete. If you would like to send comments on this time estimate to Social Security, I can provide you with the mailing address. Would you like this address?

If yes, read the Paperwork Reduction Act statement below:

Paperwork Reduction Act Statement

This information collection meets the requirements of 44 U.S.C. §3507, as amended by section 2 of the Paperwork Reduction Act of 1995. The OMB approval number is 0960-0267. You may send comments on this time estimate to: Social Security Administration, 6401 Security Blvd., Baltimore, MD 21235-6401.

Privacy Act Statement
Collection and Use of Personal Information

Section 1619(b) of the Social Security Act, as amended, authorizes us to collect this information. We will use the information you provide to make a determination of eligibility for Social Security benefits.

Furnishing us this information is voluntary. However, failing to provide us with all or part of the information may prevent an accurate and timely decision on any claim filed.

We rarely use the information you supply us for any purpose other than to make a determination regarding benefits eligibility. However, we may use the information for the administration of our programs including sharing information:

1. To comply with Federal laws requiring the release of information from our records (e.g., to the Government Accountability Office and Department of Veterans Affairs); and,

2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and improvement of our programs (e.g., to the Bureau of the Census and to private entities under contract with us).

A complete list of when we may share your information with others, called routine uses, is available in our Privacy Act System of Records Notice 60-0089, entitled, Claims Folders Systems. Additional information about this and other system of records notices and our programs are available online at www.socialsecurity.gov or at your local Social Security office.

We may share the information you provide to other health agencies through computer matching programs. Matching programs compare our records with records kept by other Federal, State or local government agencies. We use the information from these programs to establish or verify a person’s eligibility for federally funded or administered benefit programs and for repayment of incorrect payments or delinquent debts under these programs.