INSTALLMENT AGREEMENT ON BENEFICIARY REFUND OF OVERPAYMENT HCFA-PUB. 13-3, SECTION 3711.9 AND HCFA-PUB. 14-3, SECTION 7120.9 - "MEDICARE"

ICR 198903-0938-012

OMB: 0938-0211

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0211 198903-0938-012
Historical Active 198502-0938-006
HHS/CMS
INSTALLMENT AGREEMENT ON BENEFICIARY REFUND OF OVERPAYMENT HCFA-PUB. 13-3, SECTION 3711.9 AND HCFA-PUB. 14-3, SECTION 7120.9 - "MEDICARE"
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 05/18/1989
Retrieve Notice of Action (NOA) 03/22/1989
  Inventory as of this Action Requested Previously Approved
05/31/1992 05/31/1992
3,240 0 0
1,985 0 0
0 0 0

WHEN A BENEFICIARY IS OVERPAID THE CARRIER ADVISES THE BENEFICIARY OF THE ERROR AND REQUESTS A REFUND. IF THE BENEFICIARY IS UNABLE TO REFU THE FULL AMOUNT, INFORMATION IS COLLECTED FOR AN INSTALLMENT AGREEMENT

None
None


No

1
IC Title Form No. Form Name
INSTALLMENT AGREEMENT ON BENEFICIARY REFUND OF OVERPAYMENT HCFA-PUB. 13-3, SECTION 3711.9 AND HCFA-PUB. 14-3, SECTION 7120.9 - "MEDICARE" HCFA-9005

  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 3,240 0 0 0 3,240 0
Annual Time Burden (Hours) 1,985 0 0 0 1,985 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.
03/22/1989


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