'MEDICARE' REQUEST FOR CLAIM NUMBER VERIFICATION

ICR 199012-0938-002

OMB: 0938-0089

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
112843 Migrated
ICR Details
0938-0089 199012-0938-002
Historical Active 198906-0938-006
HHS/CMS
'MEDICARE' REQUEST FOR CLAIM NUMBER VERIFICATION
Revision of a currently approved collection   No
Regular
Approved without change 02/12/1991
Retrieve Notice of Action (NOA) 12/20/1990
  Inventory as of this Action Requested Previously Approved
02/28/1994 02/28/1994 02/28/1991
453,100 0 70,800
37,758 0 5,900
0 0 0

THIS FORM IS USED WHEN PROVIDERS ARE UNABLE TO OBTAIN A CORRECT NUMBER FROM THE BENEFICIARY, THE HCFA-1600 IS USED TO REQUEST CLAIM NUMBER VERIFICATION FROM THE SOCIAL SECURITY FIELD OFFICE.

None
None


No

1
IC Title Form No. Form Name
'MEDICARE' REQUEST FOR CLAIM NUMBER VERIFICATION HCFA-1600

  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 453,100 70,800 0 0 382,300 0
Annual Time Burden (Hours) 37,758 5,900 0 0 31,858 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.
12/20/1990


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