Information Collection

Application For Health Insurance Benefits Under Medicare For Individual With Chronic Renal Disease

IC 112812 under ICR 199404-0938-002 · OMB 0938-0080.

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Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

APPLICATION FOR HEALTH INSURANCE BENEFITS UNDER MEDICARE FOR INDIVIDUAL WITH CHRONIC RENAL DISEASE

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

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
Form	HCFA-43				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21,000

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	21,000	21,000
Annual IC Time Burden (Hours)	9,030	9,030
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.