THIRD PARTY PREMIUM BILLING REQUEST, MEDICARE

ICR 199312-0938-003

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
112613 Migrated
ICR Details
0938-0041 199312-0938-003
Historical Active 199008-0938-003
HHS/CMS
THIRD PARTY PREMIUM BILLING REQUEST, MEDICARE
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 03/09/1994
Retrieve Notice of Action (NOA) 12/21/1993
  Inventory as of this Action Requested Previously Approved
03/31/1997 03/31/1997
15,000 0 0
6,250 0 0
0 0 0

THE THRID PARTY PREMIUM BILLING REQUEST, HCFA-2384, IS USED AS AN AUTHORIZATION TO DESIGNATE THAT A FAMILY MEMBER OR OTHER INTERESTED PARTY RECEIVE THE MEDICARE PREMIUM BILL AND PAY IT ON BEHALF OF A MEDICARE BENEFICIARY.

None
None


No

1
IC Title Form No. Form Name
THIRD PARTY PREMIUM BILLING REQUEST, MEDICARE 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 15,000 0 0 15,000 0 0
Annual Time Burden (Hours) 6,250 0 0 6,250 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
12/21/1993


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