REQUEST FOR CLAIM NUMBER VERIFICATION

ICR 197808-0938-004

OMB: 0938-0089

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
112839 Migrated
ICR Details
0938-0089 197808-0938-004
Historical Active 197502-0938-003
HHS/CMS
REQUEST FOR CLAIM NUMBER VERIFICATION
Extension without change of a currently approved collection   No
Regular
Approved without change 08/15/1978
Retrieve Notice of Action (NOA) 08/14/1978
  Inventory as of this Action Requested Previously Approved
08/31/1983 08/31/1983 04/30/1980
600,000 0 400,000
50,000 0 32,000
0 0 0

THIS IS NOT A PUBLIC USE FORM, DESPITE CURRENT OMB APPROVAL. USED BY MEDICARE CONTRACTORS (INTERMEDIARIES) TO REQUEST INFORMATION FROM SSA DISTRICT OFFICES.

None
None


No

1
IC Title Form No. Form Name
REQUEST FOR CLAIM NUMBER VERIFICATION SSA-1600 U3

  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 600,000 400,000 0 0 200,000 0
Annual Time Burden (Hours) 50,000 32,000 0 0 18,000 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.
08/14/1978


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