MEDICARE EXCLUSION OF SERVICES REIMBURSABLE UNDER AUTOMOTIBLE, NO-FAULT OR LIABILITY INSURANCE

ICR 198208-0938-003

OMB: 0938-0263

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0263 198208-0938-003
Historical Active
HHS/CMS
MEDICARE EXCLUSION OF SERVICES REIMBURSABLE UNDER AUTOMOTIBLE, NO-FAULT OR LIABILITY INSURANCE
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 10/08/1982
Retrieve Notice of Action (NOA) 08/09/1982
  Inventory as of this Action Requested Previously Approved
09/30/1984 09/30/1984
18,138,000 0 0
52,000 0 0
0 0 0

THE INFORMATION IS NEEDED TO DETERMINE WHETHER MEDICARE PAYMENTS ARE EXCLUDED BECAUSE THE SERVICES HAVE BEEN PAID FOR OR PAYMENT CAN REASONABLY BE EXPECTED UNDER AN AUTOMOBILE MEDICAL OR NO-FAULT INSURAN POLICY OR UNDER ANY LIABILITY INSURANCE.

None
None


No

1
IC Title Form No. Form Name
MEDICARE EXCLUSION OF SERVICES REIMBURSABLE UNDER AUTOMOTIBLE, NO-FAULT OR LIABILITY INSURANCE HCFA-365

  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 18,138,000 0 0 18,138,000 0 0
Annual Time Burden (Hours) 52,000 0 0 52,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
08/09/1982


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