Information Collection

Disclosure of Eligibility Criteria for Supplemental Benefits for the Chronically Ill (SSBCI)

IC 273765 under ICR 202501-0938-009 · OMB unassigned.

Documents and Forms

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Document Name	Document Type

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IC Title:

Disclosure of Eligibility Criteria for Supplemental Benefits for the Chronically Ill (SSBCI)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.102(f)(4)(iii)(C)

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 761

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	761	761
Annual IC Time Burden (Hours)	1,522	1,522
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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