THIRD PARTY PREMIUM BILLING REQUEST

ICR 198906-0938-012

OMB: 0938-0041

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
166089 Migrated
ICR Details
0938-0041 198906-0938-012
Historical Active 198904-0938-036
HHS/CMS
THIRD PARTY PREMIUM BILLING REQUEST
No material or nonsubstantive change to a currently approved collection   No
Emergency 06/15/1989
Approved with change 06/15/1989
Retrieve Notice of Action (NOA) 06/15/1989
  Inventory as of this Action Requested Previously Approved
06/30/1990 06/30/1990 06/30/1990
10,000 0 10,000
2,500 0 2,500
0 0 0

THIS FORM IS COMPLETED BY BENEFICIARIES WHO ARE UNABLE TO MAKE THE QUARTERLY PREMIUM PAYMENTS UNDER THE SUPPLEMENTARY MEDICAL INSURANCE (SMI) PROGRAM. THE HCFA-238 SERVES AS AN AUTHORIZATION OF OTHER PERSONS TO RECEIVE THE SMI PREMIUM NOTICES AND MAKE THE PREMIUM PAYMENTS ON BEHALF OF THE BENEFICIARY.

None
None


No

1
IC Title Form No. Form Name
THIRD PARTY PREMIUM BILLING REQUEST HCFA-2384

  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 10,000 10,000 0 0 0 0
Annual Time Burden (Hours) 2,500 2,500 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.
06/15/1989


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