REQUEST FOR PART A MEDICARE HEARING BY AN ADMINISTRATIVE LAW JUDGE

ICR 199404-0938-005

OMB: 0938-0486

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
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ICR Details
0938-0486 199404-0938-005
Historical Active 199007-0938-005
HHS/CMS
REQUEST FOR PART A 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 SSA PROVIDES FOR A HEARING FOR AN INDIVIDUAL WHO I DISSATISFIED WITH THE INTERMEDIARY'S PART A DETERMINATION OR THE AMOUN PAID. THIS FORM IS USED BY THE BENEFICIARY OR OTHER QUALIFIED APPELLA TO REQUEST A HEARING BY AN ADMINISTRATIVE LAW JUDGE IF THE RECONSIDERE DETERMINATION FAILS TO SATISFY THE CLAIMANT.

None
None


No

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


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