Information Collection

Medicaid Use Report

IC 9170 under ICR 201408-0960-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
MSSICS Screens with Revised PA and PRA.pdf Other-MSSICS
MSSICS Screens.doc MSSICS Screens (current) IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-MSSICS			MSSICS Screens with Revised PA and PRA.pdf		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 %

	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

Title	Document	Date Uploaded
MSSICS Screens (current)	MSSICS Screens.doc	09/18/2014

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