Information Collection

Questionnaire To Conduct Survey Of Medicare Beneficiary Understanding Of The Explanation Of Medical Benefits

IC 116774 under ICR 199402-0990-001 · OMB 0990-0205.

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IC Title:

QUESTIONNAIRE TO CONDUCT SURVEY OF MEDICARE BENEFICIARY UNDERSTANDING OF THE EXPLANATION OF MEDICAL BENEFITS

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

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Title	Document	Date Uploaded

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