REQUEST FOR HEARING-PART B MEDICARE CLAIM

ICR 198507-0938-014

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
166072 Migrated
ICR Details
0938-0034 198507-0938-014
Historical Active 198409-0938-030
HHS/CMS
REQUEST FOR HEARING-PART B MEDICARE CLAIM
No material or nonsubstantive change to a currently approved collection   No
Emergency 07/15/1985
Approved with change 07/15/1985
Retrieve Notice of Action (NOA) 07/15/1985
  Inventory as of this Action Requested Previously Approved
06/30/1987 06/30/1987 06/30/1987
55,000 0 55,000
9,166 0 10,000
0 0 0

THE HCFA-1965 IS USED BY EITHER THE BENEFICIARY OR A PART B SUPPLIER PHYSICIAN TO REQUEST A HEARING WITH THE MEDICARE CARRIERS' HEARING OFFICER, ONCE SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS HAVE BEEN DENIED AT THE INFORMAL REVIEW STAGE.

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 55,000 55,000 0 0 0 0
Annual Time Burden (Hours) 9,166 10,000 0 0 -834 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.
07/15/1985


© 2024 OMB.report | Privacy Policy