REQUEST FOR HEARING-PART B MEDICARE CLAIM

ICR 198305-0938-016

OMB: 0938-0034

Federal Form Document

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
166070 Migrated
ICR Details
0938-0034 198305-0938-016
Historical Active 197905-0938-005
HHS/CMS
REQUEST FOR HEARING-PART B MEDICARE CLAIM
No material or nonsubstantive change to a currently approved collection   No
Emergency 05/18/1983
Approved with change 05/18/1983
Retrieve Notice of Action (NOA) 05/18/1983
  Inventory as of this Action Requested Previously Approved
05/31/1984 05/31/1984 05/31/1984
30,000 0 50,000
10,000 0 8,333
0 0 0

MEDICINE BENEFICIARIES USE THIS FORM TO REQUEST A FORMAL HEARING ON A CARRIER'S DETERMINATION OF A PART-B CLAIM, IF THE BENEFICIARY IS DISATISFIED WITH THE REQUEST OF THE INFORMAL REVIEW.

None
None


No

1
IC Title Form No. Form Name
REQUEST FOR HEARING-PART B MEDICARE CLAIM HCFA-1965

  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 30,000 50,000 0 0 -20,000 0
Annual Time Burden (Hours) 10,000 8,333 0 0 1,667 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.
05/18/1983


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