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.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

REQUEST FOR HEARING HOSPITAL INSURANCE BENEFITS PAYABLE UNDER PART A OF TITLE XVIII

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:

table that charts list of instruments
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

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,360

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	3,360	3,360
Annual IC Time Burden (Hours)	560	560
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

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