Information Collection

Medicaid Use Report

IC 9170 under ICR 202312-0960-003 · OMB 0960-0267.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SSI Claims System Screen.pdf	Other-Internal Screens
Updated PRA and PA language.docx	Other-Privacy Act Statement and Pape

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-Internal Screens			SSI Claims System Screen.pdf		Yes	Yes	Fillable Fileable Signable
Other-Privacy Act Statement and Paperwork Reduction Act (revised)			Updated PRA and PA language.docx		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 99,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 98 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	99,000	39,000	60,000
Annual IC Time Burden (Hours)	62,700	59,700	3,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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