APPLICATION FOR HOSPITAL INSURANCE

ICR 197809-0960-001

OMB: 0960-0091

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
114608 Migrated
ICR Details
0960-0091 197809-0960-001
Historical Active 197601-0960-002
SSA
APPLICATION FOR HOSPITAL INSURANCE
Revision of a currently approved collection   No
Regular
Approved without change 09/27/1978
Retrieve Notice of Action (NOA) 09/21/1978
  Inventory as of this Action Requested Previously Approved
09/30/1983 09/30/1983 01/31/1981
50,000 0 15,000
12,500 0 3,750
0 0 0

SECTION 226 OF THE SOCIAL SECURITY ACT PROVIDES THE INFORMATION REQUIRED TO DETERMINE ENTITLEMENT TO HOSTIPAL INSURANCE BENEFITS (HIB) UNDER MEDICARE IF CERTAIN CONDITIONS EXIST. THIS FORM IS USED TO DETERMINE THE APPLICANT'S ELIGIBILITY FOR HIB.

None
None


No

1
IC Title Form No. Form Name
APPLICATION FOR HOSPITAL INSURANCE SSA-18 F4

  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 50,000 15,000 0 0 35,000 0
Annual Time Burden (Hours) 12,500 3,750 0 0 8,750 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.
09/21/1978


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