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