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                      related to
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                    for more details.
 Social Security Administration
 The Social Security Administration (SSA) publishes a list of information collection packages requiring clearance by the Office of Management and Budget (OMB) in compliance with Public Law 104-13, the Paperwork Reduction Act of 1995, effective October 1, 1995. This notice includes revisions and one extension of OMB-approved information collections. SSA is soliciting comments on the accuracy of the agency's burden estimate; the need for the information; its practical utility; ways to enhance its quality, utility, and clarity; and ways to minimize burden on respondents, including the use of automated collection techniques or other forms of information technology. Mail, email, or fax your comments and recommendations on the information collection(s) to the OMB Desk Officer and SSA Reports Clearance Officer at the following addresses or fax numbers. (OMB), Office of Management and Budget, Attn: Desk Officer for SSA, Fax: 202-395-6974, Email address: 
                    *OIRA_Submission@omb.eop.gov*. (SSA), Social Security Administration, DCRDP, Attn: Reports Clearance Director, 107 Altmeyer Building, 6401 Security Blvd., Baltimore, MD 21235, Fax: 410-966-2830, Email address: 
                    *OPLM.RCO@ssa.gov*. I. The information collections below are pending at SSA. SSA will submit them to OMB within 60 days from the date of this notice. To be sure we consider your comments, we must receive them no later than June 11, 2012. Individuals can obtain copies of the collection instruments by calling the SSA Reports Clearance Officer at 410-965-8783 or by writing to the above email address. 1. 
                    *Request for Workers' Compensation/Public Disability Benefit Information—20 CFR 404.408(e)—0960-0098.*
                     Claimants for Social Security disability payments who are also receiving Worker's Compensation/Public Disability Benefits (WC/PDB) 
                    ( print page 21617)
                    must notify SSA about their WC/PDB, so the agency can compute the correct reduction of Social Security disability payments. SSA considers the claimants the primary sources of verification; therefore, if claimants provide necessary evidence, such as a copy of their award notice, benefit check, etc., that is sufficient. In cases where claimants cannot provide such evidence, SSA uses form SSA-1709. The entity paying the WC/PDB benefits, its agent, (such as an insurance carrier), or an administering public agency complete this form. The respondents are Federal, State, and local agencies, insurance carriers, and public or private self-insured companies administering WC/PDB benefits to disability claimants. *Type of Request:*
                     Revision of an OMB-approved information collection. Collection instrument
Number of 
                             respondents
Frequency of 
                             response
Average 
                             burden per 
                             response 
                             (minutes)
Estimated 
                             total annual burden (hours)SSA-1709
120,000
1
15
30,000
 2. 
                    *Claimant's Medication—20 CFR 404.1512, 416.912—0960-0289.*
                     In cases where claimants request a hearing after denial of their claim for Social Security benefits, SSA uses Form HA-4632 to obtain information from the claimant about medications they are using. This information helps the administrative law judge overseeing the case to fully investigate (1) the claimant's medical treatment and (2) the effects of the medications on the claimant's medical impairment and functional capacity. The respondents are applicants (or their representatives) for Social Security benefits or payments requesting a hearing to contest an agency denial of their claim. *Type of Request:*
                     Revision of an OMB-approved information collection. Collection method
Number of 
                             respondents
Frequency 
                             of response
Average 
                             burden per 
                             response 
                             (minutes)
Estimated 
                             total annual  
                             burden (hours)HA-4632 (paper)
20,000
1
15
5,000Electronic Records Express
180,000
1
15
45,000Total
200,000


50,000
 3. 
                    *Representative Payee Report—Special Veterans Benefits—20 CFR 408.665—0960-0621.*
                     Title VIII of the Social Security Act allows for payment of monthly Social Security benefits to qualified World War II veterans residing outside the United States. An SSA-appointed representative payee may receive and manage the monthly payment for the beneficiary's use and benefit. SSA uses the information from Form SSA-2001-F6 to determine if the payee is using the benefits properly on behalf of the beneficiary. Respondents are persons or organizations who act on behalf of beneficiaries who receive Special Veterans Benefits and live outside the United States. *Type of Request:*
                     Revision of an OMB-approved information collection. Collection instrument
Number of 
                             respondents
Frequency 
                             of response
Average 
                             burden per 
                             response 
                             (minutes)
Estimated 
                             total annual  
                             burden (hours)SSA-2001-F6
100
1
10
17
 4. 
                    *Representative Payment Policies Regulation—20 CFR 404.2011, 404.2025, 416.611, 416.625—0960-0679.*
                     If SSA determines it may cause substantial harm for beneficiaries to receive their payments directly, beneficiaries may dispute that decision. To do so, beneficiaries must provide SSA with information the agency will use to re-evaluate its determination. In addition, after SSA selects a representative payee to receive benefits on a beneficiary's behalf, the payees provide SSA with information on their continuing relationship and responsibility for the beneficiaries, and explain how they use the beneficiaries' payments. This Information Collection Request includes the CFR citations that mandate the above provisions. *Type of Request:*
                     Extension of an OMB-approved information collection. CFR Section
Number of
                             respondents
Frequency 
                             of response
Average 
                             burden per 
                             response 
                             (minutes)
Estimated
                             annual 
                             burden 
                             (hours)404.2011(a)(1), 416.611(a)(1)
250
1
15
63404.2025, 416.625
3,000
1
6
300Totals
3,250


363
 
 
 II. SSA submitted the information collection below to OMB for clearance. Your comments regarding the information collection would be most useful if OMB and SSA receive them within 30 days from the date of this publication. To be sure we consider your comments, we must receive them no later than May 10, 2012. Individuals can obtain copies of the OMB clearance packages by calling the SSA Reports Clearance Director at 410-965-8783 or by writing to the above email address. *Third Party Liability Information Statement—42 CFR 433.136-433.139—0960-0323.*
                     States may enter into agreements with the Commissioner of Social Security to make Medicaid eligibility determinations for aged, blind, and disabled beneficiaries in those states. Applications for and redeterminations of SSI eligibility in jurisdictions with such agreements are applications and redeterminations of Medicaid eligibility. To reduce Medicaid costs, Medicaid state agencies must identify third party insurers liable for medical care or services for Medicaid beneficiaries. Regulations at 42 CFR 433.136-433.139 require Medicaid state agencies to obtain this information on Medicaid applications and redeterminations as a condition of Medicaid eligibility. The Medicaid state agencies use the information to bill third parties liable for medical care, support, or services for a beneficiary to guarantee that Medicaid remains the payer of last resort. Under the Medicaid agreements, SSA obtains third party liability information using Form SSA-8019, and provides that information to the Medicaid state agencies. The respondents are SSI claimants and recipients. Note: This is a correction notice: SSA published this information collection as an extension on January 31, 2012 at 77 FR 4854. Since we are revising the Privacy Act Statement, this is now a revision of an OMB-approved information collection. *Type of Request:*
                     Revision of an OMB-approved information collection. Collection instrument
Number of 
                             responses
Frequency 
                             of response
Average 
                             burden per 
                             response 
                             (minutes)
Estimated 
                             total annual  
                             burden (hours)SSA-8012 Paper form
130
1
5
11Modernized SSI Claims System (MSSICS)
66,904
1
5
5,575Totals
67,034


5,586
 Dated: April 5, 2012. Faye Lipsky, Reports Clearance Director, Office of Regulations and Reports Clearance, Social Security Administration.


[FR Doc. 2012-8546 Filed 4-9-12; 8:45 am] BILLING CODE 4191-02-P