MEDICARE - APPLICATION FOR HOSPITAL INSURANCE

ICR 199103-0938-006

OMB: 0938-0251

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
113264 Migrated
ICR Details
0938-0251 199103-0938-006
Historical Active 198908-0938-007
HHS/CMS
MEDICARE - APPLICATION FOR HOSPITAL INSURANCE
Extension without change of a currently approved collection   No
Regular
Approved without change 06/03/1991
Retrieve Notice of Action (NOA) 03/18/1991
  Inventory as of this Action Requested Previously Approved
05/31/1994 05/31/1994 05/31/1991
50,000 0 50,000
12,500 0 12,500
0 0 0

THE HCFA-18F5 IS USED TO ESTABLISH HI ENTITLEMENT AND SMI ENROLLMENT F DISTINCT CLASSIFICATIONS OF BENEFICIARIES NOT COVERED BY REGULAR TITLE II SOCIAL SECURITY BENEFITS.

None
None


No

1
IC Title Form No. Form Name
MEDICARE - APPLICATION FOR HOSPITAL INSURANCE HCFA-18E5

  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 50,000 50,000 0 0 0 0
Annual Time Burden (Hours) 12,500 12,500 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.
03/18/1991


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