REQUEST FOR REVIEW OF PART B MEDICARE CLAIM

ICR 197712-0938-006

OMB: 0938-0033

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
166067 Migrated
ICR Details
0938-0033 197712-0938-006
Historical Active 197706-0938-001
HHS/CMS
REQUEST FOR REVIEW OF PART B MEDICARE CLAIM
No material or nonsubstantive change to a currently approved collection   No
Emergency 12/06/1977
Approved with change 12/06/1977
Retrieve Notice of Action (NOA) 12/06/1977
  Inventory as of this Action Requested Previously Approved
05/31/1979 05/31/1979 05/31/1979
600,000 0 50,000
150,000 0 12,500
0 0 0



None
None


No

1
IC Title Form No. Form Name
REQUEST FOR REVIEW OF PART B MEDICARE CLAIM SSA-1964

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 600,000 50,000 0 0 550,000 0
Annual Time Burden (Hours) 150,000 12,500 0 0 137,500 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
12/06/1977


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