Information Collection

Request For Medical Payment

IC 177088 under ICR 198004-3220-013 · OMB 3220-0085.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0085 can be found here:

Documents and Forms

Document Name Document Type

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Information Collection (IC) Details

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IC Title:	REQUEST FOR MEDICAL PAYMENT	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	G-740				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,300,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,300,000	1,300,000
Annual IC Time Burden (Hours)	130,000	130,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.