Request for Part B Medicare Hearing by an Administrative Law Judge and Supporting Regulations in 42 CFR 498, Subpart D and E

ICR 199706-0938-003

OMB: 0938-0567

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0567 199706-0938-003
Historical Active 199404-0938-004
HHS/CMS
Request for Part B Medicare Hearing by an Administrative Law Judge and Supporting Regulations in 42 CFR 498, Subpart D and E
Extension without change of a currently approved collection   No
Regular
Approved without change 08/08/1997
Retrieve Notice of Action (NOA) 06/13/1997
  Inventory as of this Action Requested Previously Approved
10/31/2000 10/31/2000 08/31/1997
10,000 0 10,000
2,500 0 2,500
0 0 0

Section 1869 of the Social Security Act authorizes a hearing for any individual who is dissatisfied with the carrier's Part B determination or the amount paid. This form is used by the beneficiary or other qualified appellant to request a hearing by an Administrative Law Judge if the hearing officer's 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 and Supporting Regulations in 42 CFR 498, Subpart D and E 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 10,000 0 0 0 0
Annual Time Burden (Hours) 2,500 2,500 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
06/13/1997


© 2024 OMB.report | Privacy Policy