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) - 2026 Forward

IC 277535 under ICR 202605-0970-009 · OMB 0970-0222.

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) - 2026 Forward	Form
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) - 2026 Forward	Form
NMSN Part A_Sample_Clean.docx	Instruction
NMSN Part A_Sample_Clean.docx	Instruction
2025_06_11_e-NMSN_Software_Interface_Specification__Clean.pdf	Instruction
2025_06_11_e-NMSN_Software_Interface_Specification__Clean.pdf	Instruction
NMSN_Supplemental_Instructions_clean_10.1.docx	Instruction
NMSN_Supplemental_Instructions_clean_10.1.docx	Instruction
1 National Medical Support Notice Part A NMSN Part A clean.docx	Form
1 National Medical Support Notice Part A NMSN Part A clean.docx	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) - 2026 Forward

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
Form	1	Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Printable Only

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: 6

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	30,000	-5,000	35,000
Annual IC Time Burden (Hours)	317	-33	350
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.

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