Information Collection

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

IC 8118 under ICR 200102-0938-004 · OMB 0938-0501.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0501 can be found here:

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Information Collection (IC) Details

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IC Title:	Medicare Qualification Statement for Federal Employees and Supporting Regulations in 42 CFR 406.15	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-565				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,300	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,300	4,300
Annual IC Time Burden (Hours)	731	731
Annual IC Cost Burden (Dollars)	0	0

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Title	Document	Date Uploaded

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