Information Collection

National Medical Support Notice – Part A – Notice to Withhold for Health Care Coverage e-NMSN record specification layout Electronic system to system (State Respondents)

IC 264134 under ICR 202504-0970-026 · OMB 0970-0222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 National Medical Support Notice Part A National Medical Support Notice – Part A – Notice to Withhold for Health Care Coverage e-NMSN record specification layout Electronic system to system (State Respondents)	Form
2023 02 23 NMSN_Part_A_Sample_Form Clean.docx	Instruction
2023 02 23 NMSN_Part_A_Sample_Form Clean.docx	Instruction
2023_08_23_e-NMSN_Software_Interface_Specification_Main_Body_V1_6_DRAFT.docx	Instruction
2023_08_23_e-NMSN_Software_Interface_Specification_Main_Body_V1_6_DRAFT.docx	Instruction
2023_08_23_e-NMSN_Software_Interface_Specification_Appendix_A_V1_6_DRAFT.docx	Instruction
2023_08_23_e-NMSN_Software_Interface_Specification_Appendix_A_V1_6_DRAFT.docx	Instruction
2023_08_23_e-NMSN_Software_Interface_Specification_Appendix_B_V1_6_DRAFT.docx	Instruction
2023_08_23_e-NMSN_Software_Interface_Specification_Appendix_B_V1_6_DRAFT.docx	Instruction
2023_08_23_e-NMSN_Software_Interface_Specification_Appendix_C_V1_6_DRAFT.docx	Instruction
2023_08_23_e-NMSN_Software_Interface_Specification_Appendix_C_V1_6_DRAFT.docx	Instruction
2023_08_23_e-NMSN_Software_Interface_Specification_Appendix_D_V1_6_DRAFT.docx	Instruction
2023_08_23_e-NMSN_Software_Interface_Specification_Appendix_D_V1_6_DRAFT.docx	Instruction
2023_08_23_e-NMSN_Software_Interface_Specification_Appendix_E_V1_6_DRAFT.docx	Instruction
2023_08_23_e-NMSN_Software_Interface_Specification_Appendix_E_V1_6_DRAFT.docx	Instruction
2023_08_23_e-NMSN_Software_Interface_Specification_Appendix_F_V1_6_DRAFT.docx	Instruction
2023_08_23_e-NMSN_Software_Interface_Specification_Appendix_F_V1_6_DRAFT.docx	Instruction
1 National Medical Support Notice Part A omb_0970_0222_a.pdf	Form
1 National Medical Support Notice Part A omb_0970_0222_a.pdf	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

National Medical Support Notice â Part A â Notice to Withhold for Health Care Coverage e-NMSN record specification layout Electronic system to system (State Respondents)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction		Yes	Yes	Fillable Printable
Instruction		Yes	Yes	Printable Only
Instruction		Yes	Yes	Printable Only
Instruction		Yes	Yes	Printable Only
Instruction		Yes	Yes	Printable Only
Instruction		Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Printable Only
Instruction		Yes	Yes	Printable Only
Form	1	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	25,000	25,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	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.

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