Emergency and Foreign Hospital Services -- Beneficiary Statement in Canadian Travel Claims and Supporting Regulations in 42 CFR, Section 424.123

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0484 can be found here:

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Emergency and Foreign Hospital Services -- Beneficiary Statement in Canadian Travel Claims and Supporting Regulations in 42 CFR, Section 424.123	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-R-96				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,100	1,100
Annual IC Time Burden (Hours)	275	275
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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