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Information Collection

Request For Hearing Hospital Insurance Benefits Payable Under Part A Of Title Xviii

IC 115323 under ICR 198212-0960-007 · OMB 0960-0327.

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Information Collection (IC) Details

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REQUEST FOR HEARING HOSPITAL INSURANCE BENEFITS PAYABLE UNDER PART A OF TITLE XVIII
 
No Migrated
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form HA-5011 No No
Form (7-81) No No


    

3,360 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 3,360 0 0 3,360 0 0
Annual IC Time Burden (Hours) 560 0 0 560 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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