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

ICR 200008-0938-005

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 200008-0938-005
Historical Active 199706-0938-003
HHS/CMS
Request for Hearing for Part B Medicare 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 10/02/2000
Retrieve Notice of Action (NOA) 08/21/2000
  Inventory as of this Action Requested Previously Approved
10/31/2003 10/31/2003 10/31/2000
1,000 0 10,000
2,500 0 2,500
0 0 0

Seciton 1869 of the Social Security Act authorizes a hearing for any individual who is dissatisfied with the carrier's determination or amount of benefit paid. This form is used by the beneficiary or other quqlified appellant to request a hearing by an Administrative Law Judge because the hearing officer's decision failed to satisfy the appellant.

None
None


No

1
IC Title Form No. Form Name
Request for Hearing for Part B Medicare 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 1,000 10,000 0 -9,000 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.
08/21/2000


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