Medicare Qualification Statement for Federal Employees and Supporting Regulations in 42 CFR 406.15

ICR 200102-0938-004

OMB: 0938-0501

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0501 200102-0938-004
Historical Active 199711-0938-004
HHS/CMS
Medicare Qualification Statement for Federal Employees and Supporting Regulations in 42 CFR 406.15
Reinstatement without change of a previously approved collection   No
Regular
Approved without change 04/16/2001
Retrieve Notice of Action (NOA) 02/08/2001
Approved for use through 4/2004 under the condition that prior to the form's next printing,HCFA deletes the OMB address from the PRA dislosure statement.
  Inventory as of this Action Requested Previously Approved
04/30/2004 04/30/2004
4,300 0 0
731 0 0
0 0 0

The HCFA-565 is completed by individuals filing for hospital insurance (HI) or Part A benefits based upon their federal employment. This information is needed to determine if SSA/HCFA can use (or deem) federal employment prior to 1983 to qualify for free Hospital Insurance.

None
None


No

1
IC Title Form No. Form Name
Medicare Qualification Statement for Federal Employees and Supporting Regulations in 42 CFR 406.15 HCFA-565

  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 4,300 0 0 4,300 0 0
Annual Time Burden (Hours) 731 0 0 731 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
02/08/2001


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