REQUEST FOR HEARING-PART B MEDICARE CLAIM

ICR 198706-0938-001

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
112582 Migrated
ICR Details
0938-0034 198706-0938-001
Historical Active 198507-0938-014
HHS/CMS
REQUEST FOR HEARING-PART B MEDICARE CLAIM
Extension without change of a currently approved collection   No
Regular
Approved without change 08/07/1987
Retrieve Notice of Action (NOA) 06/08/1987
  Inventory as of this Action Requested Previously Approved
06/30/1990 06/30/1990 06/30/1987
55,000 0 55,000
9,166 0 9,166
0 0 0

THE HCFA-1965 IS USED BY EITHER THE BENEFICIARY O 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 9,166 0 0 0 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.
06/08/1987


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