APPLICATION FOR REIMBURSEMENT FOR HOSPITAL INSURANCE SERVICES IN CANADA

ICR 199008-3220-002

OMB: 3220-0086

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
3220-0086 199008-3220-002
Historical Active 198708-3220-002
RRB
APPLICATION FOR REIMBURSEMENT FOR HOSPITAL INSURANCE SERVICES IN CANADA
Extension without change of a currently approved collection   No
Regular
Approved without change 10/17/1990
Retrieve Notice of Action (NOA) 08/08/1990
  Inventory as of this Action Requested Previously Approved
10/31/1993 10/31/1993 10/31/1990
123 0 123
21 0 21
0 0 0

THE BOARD ADMINISTERS THE MEDICARE PROGRAM FOR PERSONS COVERED BY THE RAILROAD RETIREMENT SYSTEM. THE COLLECTION OBTAINS THE INFORMATION NEEDED TO DETERMINE ELIGIBILITY FOR AMOUNT DUE FOR COVERED HOSPITAL SERVICES RECEIVED IN CANADA.

None
None


No

1
IC Title Form No. Form Name
APPLICATION FOR REIMBURSEMENT FOR HOSPITAL INSURANCE SERVICES IN CANADA AA-104

  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 123 123 0 0 0 0
Annual Time Burden (Hours) 21 21 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.
08/08/1990


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