REQUEST FOR REVIEW PART B MEDICARE CLAIM

ICR 198003-3220-005

OMB: 3220-0100

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
157642 Migrated
ICR Details
3220-0100 198003-3220-005
Historical Active 197502-3220-009
RRB
REQUEST FOR REVIEW PART B MEDICARE CLAIM
Revision of a currently approved collection   No
Regular
Approved without change 04/01/1980
Retrieve Notice of Action (NOA) 03/05/1980
  Inventory as of this Action Requested Previously Approved
03/31/1981 03/31/1981 04/30/1980
4,100 0 4,000
1,025 0 1,000
0 0 0

THE BOARD ADMINISTERS THE MEDICARE PROGRAM FOR PERSONS COVERED BY THE RAILROAD RETIREMENT SYSTEM. THE REQUEST PROVIDES THE MEANS FOR OBTAINING A REVIEW OF THE DETERMINATION MADE BY TRAVELERS ON A CLAIM FOR PART B BENEFITS.

None
None


No

1
IC Title Form No. Form Name
REQUEST FOR REVIEW PART B MEDICARE CLAIM G-790

  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 4,100 4,000 0 0 100 0
Annual Time Burden (Hours) 1,025 1,000 0 0 25 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.
03/05/1980


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