Request for Review of Part B Medicare Claim

ICR 200210-3220-002

OMB: 3220-0100

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
33905 Migrated
ICR Details
3220-0100 200210-3220-002
Historical Active 199909-3220-002
RRB
Request for Review of Part B Medicare Claim
Extension without change of a currently approved collection   No
Regular
Approved without change 01/02/2003
Retrieve Notice of Action (NOA) 10/03/2002
  Inventory as of this Action Requested Previously Approved
01/31/2006 01/31/2006 01/31/2003
4,100 0 4,100
1,025 0 1,025
0 0 0

The Railroad Retirement Board administers the Medicare program for persons covered by the railroad retirement system. The request provides the means for obtaining reviews by Palmetto GBA on claims for Part B Medicare benefits.

None
None


No

1
IC Title Form No. Form Name
Request for Review of Part B Medicare Claim G-790, G-791

  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 4,100 4,100 0 0 0 0
Annual Time Burden (Hours) 1,025 1,025 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.
10/03/2002


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