Medicaid Use Report

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 09600267. 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.