Information Collection

Questions On Other Insurance Available To Medicare Beneficairy, Hcfa-pub. 13-1, Section 3689, And Hcfr-pub. 14-3, Section 3000

IC 113134 under ICR 198502-0938-011 · OMB 0938-0214.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0214 can be found here:

Documents and Forms

Document Name Document Type

No indexed documents/forms are available for this IC yet. A refresh has been queued.

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	QUESTIONS ON OTHER INSURANCE AVAILABLE TO MEDICARE BENEFICAIRY, HCFA-PUB. 13-1, SECTION 3689, AND HCFR-PUB. 14-3, SECTION 3000	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-9009				No	No
Form	HCFA-L-365				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 773,074	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	773,074	-82,827	855,901
Annual IC Time Burden (Hours)	90,453	19,128	71,325
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

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