Medicare-only MCS SSA-1 screens

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⚠️ Notice: This information collection may be referencing outdated material.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
SSA-1 MCS Screens (IC 2).pdf in field office Other-MCS screens for Medicare-only
PCS Screen Package.pdf Other-Intranet Screens
PCS Privacy Act Statement.pdf Other-Privacy Act Statement for PCS

Information Collection (IC) Details

IC Title:	Medicare-only MCS SSA-1 screens	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.1501-.1512 20 CFR 404.315-.322 20 CFR 404.330-.333 20 CFR 404.310-.311 20 CFR 404.601-.603

Information Collection Instruments:

Document Type	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-MCS screens for Medicare-only (will be modified in interview as necessary)	SSA-1 MCS Screens (IC 2).pdf	in field office	Yes	Yes	Fillable Fileable Signable
Other-Intranet Screens	PCS Screen Package.pdf		Yes	Yes	Fillable Fileable Signable
Other-Privacy Act Statement for PCS	PCS Privacy Act Statement.pdf		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 204,380	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-204,380	204,380
Annual IC Time Burden (Hours)	-23,844	23,844
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.