APPLICATION FOR REIMBURSEMENT FOR HOSPITAL INSURANCE SERVICE IN CANADA

ICR 198105-3220-036

OMB: 3220-0086

Federal Form Document

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ICR Details
3220-0086 198105-3220-036
Historical Active 198105-3220-018
RRB
APPLICATION FOR REIMBURSEMENT FOR HOSPITAL INSURANCE SERVICE IN CANADA
No material or nonsubstantive change to a currently approved collection   No
Emergency 05/29/1981
Approved with change 05/29/1981
Retrieve Notice of Action (NOA) 05/29/1981
  Inventory as of this Action Requested Previously Approved
08/31/1981 08/31/1981 05/31/1981
600 0 600
100 0 100
0 0 0

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 AGENT IN CANADA, ONTARIO BLUE CROSS, TO PAY FOR COVERED MEDICAL SERVICES IN CANADA.

None
None


No

1
IC Title Form No. Form Name
APPLICATION FOR REIMBURSEMENT FOR HOSPITAL INSURANCE SERVICE IN CANADA AA-104

  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 600 600 0 0 0 0
Annual Time Burden (Hours) 100 100 0 0 0 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.
05/29/1981


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