Emergency and Foreign Hospital Services, Beneficiary Statement in Canadian Travel Claims

ICR 199612-0938-001

OMB: 0938-0484

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
0938-0484 199612-0938-001
Historical Active 199401-0938-002
HHS/CMS
Emergency and Foreign Hospital Services, Beneficiary Statement in Canadian Travel Claims
Extension without change of a currently approved collection   No
Regular
Approved without change 02/10/1997
Retrieve Notice of Action (NOA) 12/13/1996
  Inventory as of this Action Requested Previously Approved
04/30/2000 04/30/2000 03/31/1997
1,100 0 1,700
275 0 425
0 0 0

This statement must be submitted by the beneficiary to support claim for payment.

None
None


No

1
IC Title Form No. Form Name
Emergency and Foreign Hospital Services, Beneficiary Statement in Canadian Travel Claims HCFA-R-96

  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 1,100 1,700 0 -600 0 0
Annual Time Burden (Hours) 275 425 0 -150 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes

$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.
12/13/1996


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