Medicaid Use Report

COLLECTION INSTRUMENT – Medicaid Use Report – OMB #0960-0267
The beneficiary’s answers to the following questions must be recorded on a Statement of
Claimant or Other Person (SSA-795), or in MSSICS on the DPST or DROC screens.
Per SI 02302.040, the individual should be asked:
• “Have you used any medical care or services in the past 12 months that was paid
for by Medicaid (or Medi-Cal, etc.)?”
• “Do you expect to receive any medical care or services in the next 12 months that
will be paid for by Medicaid (or Medi-Cal, etc.)?”
• “Without Medicaid (Medi-Cal, etc.), would you be unable to pay your medical
bills if you become ill or injured in the next 12 months?”
Based on the individual’s allegations regarding Medicaid use, the technician will transmit
the appropriate finding to the SSR per SM 01305.975.
FACSIMILE: DPST - PERSON STATEMENT (MSOM 022.008)
MSSICS
PERSON STATEMENT
PAGE 1 OF DPST
SSS-SS-SSSS
SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
SELECT CLAIMANT/PERSON: 99
NAME:
RELATIONSHIP/TITLE
1=SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSS SSSS
2=SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSS SSSS
3=SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSS SSSS
4=SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSS SSSS
5=SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSS SSSS

FACSIMILE: DROC - REPORT OF CONTACT (MSOM 022.010)
MSSICS
REPORT OF CONTACT
PAGE 1 OF DROC
SSS-SS-SSSS
SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
SELECT CLAIMANT/PERSON: 99
NAME:
RELATIONSHIP/TITLE:
1=SSSSSSSSSSSSSS SSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSS
2=SSSSSSSSSSSSSS SSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSS
3=SSSSSSSSSSSSSS SSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSS
4=SSSSSSSSSSSSSS SSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSS
5=SSSSSSSSSSSSSS SSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSS SSSS

Privacy Act Statement
Collection and Use of Personal Information

Section 205(a) of the Social Security Act, as amended, [42 U.S.C. 405(a)] authorizes us
to collect this information. We will use the information you provide to help us determine
the identity of your spouse. The information you furnish on this form is voluntary.
However, failure to provide the requested information may prevent us from paying
benefits to your spouse.
We rarely use the information you supply for any purpose other than for determining the
identity of a spouse. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not
limited to the following:
See revised
1. To enable a third party or an agency Privacy
to assist Social
Act Security in establishing rights to
Social Security benefits and/or coverage;
Statement below.
2. To comply with Federal laws requiring the release of information from Social Security
records (e.g., to the Government Accountability Office and Department of Veterans
Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, state, and local level; and
4. To facilitate statistical research and audit activities necessary to assure the integrity and
improvement of Social Security programs (e.g., to the Bureau of the Census and private
entities under contract with us).
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, state, or local
government agencies. We use the information from these matching programs to establish
or verify a person’s eligibility for Federally-funded or administered benefit programs and
for repayment of incorrect payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Systems of Records
Notices entitled Claims Folders Systems, 60-0089 and Master Beneficiary Record 600090. The notices, additional information regarding this form, and information regarding
our systems and programs, are available on-line at www.ssa.gov or at any local Social
Security office.
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. §3507, as amended by Section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
revise
PRA We estimate that it will take about 3
of Management and BudgetSee
control
number.
Statement
minutes to read the instructions,
gatherbelow.
the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at

www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). You may send comments on our time estimate above to: SSA, 6401
Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.

Read to participant at the beginning of interview:
Social Security estimated that this interview would take 3 minutes to complete. If you
would like to send comments on this time estimate to Social Security, I can provide you
with the mailing address. Would you like this address?
If yes, read the Paperwork Reduction Act statement below:
This information collection meets the requirements of 44 U.S.C. §3507, as amended by
section 2 of the Paperwork Reduction Act of 1995. The OMB approval number is
0960-0267. You may send comments on this time estimate to: Social Security
Administration, 6401 Security Blvd., Baltimore, MD 21235-6401.

January 28, 2014

Page 1 of 1

Privacy Act Statement
Collection and Use of Personal Information
Section 1619(b) of the Social Security Act, as amended, authorizes us to collect this information.
We will use the information you provide to make a determination of eligibility for Social
Security benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination
regarding benefits eligibility. However, we may use the information for the administration of
our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0089, entitled, Claims Folders
Systems. Additional information about this and other system of records notices and our
programs are available online at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.