REQUEST FOR PAYMENT BY QUALIFIED ORGANIZATIONS

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
157595	REQUEST FOR PAYMENT BY QUALIFIED ORGANIZATIONS Form	Migrated

ICR Details

OMB Control No: 3220-0091	ICR Reference No: 198101-3220-001
Status: Historical Inactive	Previous ICR Reference No: 198006-3220-001
Agency/Subagency: RRB	Agency Tracking No:
Title: REQUEST FOR PAYMENT BY QUALIFIED ORGANIZATIONS
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Disapproved	Conclusion Date: 02/05/1981
	Date Received in OIRA: 01/08/1981
Terms of Clearance: IN JUNE 1980 THE G-740B WAS APPROVED FOR THREE MONTHS ONLY, UNTIL SEPTEMBER 1980, "TO ALLOW RRB SUFFICIENT TIME TO PREPARE A CLEARANCE REQUEST TO USE THE REVISED HCFA/CHAMPUS FORM (THE AMA STANDARD FORM) INSTEAD." APPROVAL FOR USE OF THE G-740B EXPIRED 9/30/80. USE SINCE THEN HAS BEEN IN VIOLATION OF LAW (44USC3509). THE NEW HCFA FORM IS AVAILABLE AND MUST BE USED AS SOON AS POSSIBLE. RRB SHOULD QUICKLY RESUBMIT A REQUEST FOR APPROVAL, INCLUDING AN EXPLANATION AND CATEGORIZATION OF CHANGE IN BURDEN, USING OMB'S ACCOUNTING TERMS.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		09/30/1980
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: THE BOARD ADMINISTERS THE MEDICARE PROGRAM FOR PERSONS COVERED BY THE RAILROAD RETIREMENT SYSTEM. THE REQUEST WILL OBTAIN INFORMATION TO BE USED BY THE BOARD'S CARRIER, TRAVELERS, TO PAY RAILROAD HOSPITAL ASSOCIATIONS FOR MEDICAL SERVICES COVERED UNDER PART B OF THE PROGRAM.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
REQUEST FOR PAYMENT BY QUALIFIED ORGANIZATIONS	G-740B

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 01/08/1981

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