Medicare-only iClaim

Social Security Benefits Application

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0618 can be found here:

Documents and Forms

Document Name Document Type
iClaim - Revised Screens.pdf www.socialsecurity.gov Other-Internet screens
Revised iClaim PA Statments Screen.pdf www.socialsecurity.gov Other-Internet Screen
iClaim - Current Screens.pdf Currently Approved iClaim Screens IC Document
Current iClaim PA Statments Screen.pdf Current iClaim Privacy Act Statements IC Document

Information Collection (IC) Details

IC Title:	Medicare-only iClaim	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 404.315-.322 20 CFR 404.330-.333 20 CFR 404.601-.603 20 CFR 404.1501-.1512 20 CFR 404.310-.311

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Internet screens			iClaim - Revised Screens.pdf	http://www.socialsecurity.gov	Yes	Yes	Fillable Fileable Signable
Other-Internet Screen			Revised iClaim PA Statments Screen.pdf	http://www.socialsecurity.gov	Yes	Yes	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 797,709	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	797,709	74,647	723,062
Annual IC Time Burden (Hours)	132,952	12,442	120,510
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Currently Approved iClaim Screens	iClaim - Current Screens.pdf	08/06/2013
Current iClaim Privacy Act Statements	Current iClaim PA Statments Screen.pdf	08/06/2013

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