REQUEST FOR PART B MEDICARE HEARING BY AN ADMINISTRATIVE LAW JUDGE

ICR 199404-0938-004

OMB: 0938-0567

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0567 199404-0938-004
Historical Active 199007-0938-002
HHS/CMS
REQUEST FOR PART B MEDICARE HEARING BY AN ADMINISTRATIVE LAW JUDGE
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 06/16/1994
Retrieve Notice of Action (NOA) 04/14/1994
  Inventory as of this Action Requested Previously Approved
08/31/1997 08/31/1997
10,000 0 0
2,500 0 0
0 0 0

SECTION 1869 OF THE SOCIAL SECURITY ACT WAS AMENDED TO PROVIDE FOR A HEARING FOR AN INDIVIDUAL WHO IS DISSATISFIED WITH THE CARRIER'S HEARI DECISION OR THE AMOUNT PAID. THIS FORM IS USED BY THE BENEFICIARY OR OTHER QUALIFIED APPELLANT TO REQUEST A HEARING BY AN ADMINISTRATIVE LA JUDGE IF THE CARRIER HEARING DECISION FAILS TO SATISFY THE APPELLANT.

None
None


No

1
IC Title Form No. Form Name
REQUEST FOR PART B MEDICARE HEARING BY AN ADMINISTRATIVE LAW JUDGE HCFA-5011B, U6

  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 10,000 0 0 10,000 0 0
Annual Time Burden (Hours) 2,500 0 0 2,500 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.
04/14/1994


© 2024 OMB.report | Privacy Policy