Medicare-only iClaim

Social Security Benefits Application

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0618 can be found here:

Documents and Forms

Document Name Document Type
iClaim - Revised Screens.pdf www.socialsecurity.gov Other-Internet screens
iClaim Screens - Current and Revised (select screens only).pdf www.ssa.gov Other-Internet Screens
iClaim Screens - Current and Revised (select screens only).pdf Currently Approved iClaim Screens IC Document

Information Collection (IC) Details

IC Title:	Medicare-only iClaim	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.315-.322 20 CFR 404.330-.333 20 CFR 404.601-.603 20 CFR 404.1501-.1512 20 CFR 404.310-.311

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Internet Screens			iClaim Screens - Current and Revised (select screens only).pdf	www.ssa.gov	Yes	Yes	Fillable Fileable Signable
Other-Internet screens			iClaim - Revised Screens.pdf	http://www.socialsecurity.gov	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: 797,709	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	797,709	797,709
Annual IC Time Burden (Hours)	132,952	132,952
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Currently Approved iClaim Screens	iClaim Screens - Current and Revised (select screens only).pdf	02/13/2019

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