Information Collection

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

IC 8165 under ICR 200008-0938-005 · OMB 0938-0567.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-5011B-U6				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,000	-9,000	10,000
Annual IC Time Burden (Hours)	2,500	0	2,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

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