Information Collection

Medicare - Questions On Other Insurance Available To Medicare Beneficary

IC 113137 under ICR 198801-0938-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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Information Collection (IC) Details

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IC Title:	MEDICARE - QUESTIONS ON OTHER INSURANCE AVAILABLE TO MEDICARE BENEFICARY	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

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: 3,854,074	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,854,074	3,081,000	773,074
Annual IC Time Burden (Hours)	336,933	246,480	90,453
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.