Approved for use
through 3/91 under the condition that the next submission for OMB
approval contains a status report on the progress in implementing
the Claims Modernization Project and utilizing data already
collected in retirement and disability claims submitted to the
Social Security Administration.
Inventory as of this Action
Requested
Previously Approved
03/31/1991
03/31/1991
13,500
0
0
5,850
0
0
0
0
0
THE LAW REQUIRES THE FILIN OF AN
APPLICATION TO ESTABLISH MEDICARE ENTITLEMENT BASED ON END-STAGE
RENAL DISEASE. THE HCFA-43 IS THE APPLICATION FORM USED TO OBTAIN
INFORMATION NEEDED TO DETERMINE MEDICARE ELIGIBILITY. IT GUIDES
DISTRICT OFFICE PERSONNEL IN SECURING THE REQUIRED DEVELOPMENT AND
BECOMES A PERMANENT PART OF THE CLAIMS FILE.
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.