Information Collection

Medicare Qualification Statement For Federal Employees "medicare"

IC 113880 under ICR 198904-0938-004 · OMB 0938-0501.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0501 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	MEDICARE QUALIFICATION STATEMENT FOR FEDERAL EMPLOYEES "MEDICARE"	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-565				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,300	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,300	1,942	2,358
Annual IC Time Burden (Hours)	731	330	401
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.